CASE STUDY - WEEK 5 - HALEY 10YRS OLD - CC: ASTHMA
QUESTION 2
The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by
NPs and other healthcare professionals and includes:
S: subjective information provided by the patient
O: objective information obtained by the provider
A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information
has already been provided to you in the case.
P: medical plan.
Write a brief SOAP note addressing Haley’s presentation to the clinic and chief complaint. Be sure to
include each component: SOAP. A reference is not required for this question.
Answer:
S:
"I can't stop coughing"
HPI: Haley, a 10-year old presents to the clinic accompanied by her parents complaining of a persistent
cough. She has a history of asthma and reports getting up 3-4 nights to use her albuterol inhaler, in
addition to this morning before the office visit. She experiences wheezing 3-4 times a week especially
when at the gym or in contact with a cat. Current medications include a SABA.
PMI: history of asthma, NKDA
Family Hx: Mother- asthma; Father- hypertension, current smoker; no siblings
Social Hx: well balanced diet with occasional fast food; gym at school and plays outside daily until
symptoms of asthma occur; doing well in school
Review of Systems:
General: No recent change of weight, no fever, chills, diaphoresis
Cardiovascular: Denies chest pain, palpations, edema, report dyspnea.
Respiratory: reports shortness of breath, wheezing, chest tightness, cough, denies hemoptysis
and pleurisy
HEENT: Denies headache, rhinorrhea, or sinus congestion
GI: denies constipation, diarrhea, and other stool abnormalities
GU: denies dysurea
Musculoskeletal: denies back/neck pain or weakness
Psychiatric: denies depression, anxiety, or suicidal ideations
O:
This study source was downloaded by 100000838928381 from CourseHero.com on 06-15-2022 09:17:18 GMT -05:00
https://www.coursehero.com/file/125880474/WEEK-5-ASTHMA-CASE-STUDYdocx/
, Vitals: T:98.2, RR:24. HR:118, BP108/64, SaO2:92%
Height: 56 inches Weight: 72 pounds BMI: 16.1
General: Alert and oriented to person, place, time, and situation, in slight respiratory
distress.
HEENT: PERRLA, no nasal flaring nasal polyps, no swelling of the lymph nodes.
Neck: no JVD, full ROM
Thorax: there is limited chest expansion with use of accessory muscles
Lungs: wheezing, diffuse wheezes bilaterally on expiration and occasionally on inspiration; presence of
breath sounds, decreased breath sounds bilaterally with tight air movement
Heart: Tachycardia with s1 and s2 regular rate and rhythm.
Neurological: cranial nerves intact
A:
Asthma
P:
Haley and her family need to be educated on asthma, its symptoms, and the use of an inhaler.
The patient and her family also need to demonstrate using the metered dose inhaler and spacers.
Haley and her father need to be educated on compliance with the medication regimen to reduce the risk
of asthma-related exacerbation, hospitalizations, and deaths.
The patient and her family need to be educated on the avoidance of triggering factors like pets.
A written asthma action plan needs to be provided with information on asthma, medication change,
including dose, route, and frequency.
Information needs to be provided on recognizing the worsening of symptoms and seeking medical help,
if needed, to Haley and her family.
Haley's father needs to be educated on smoking cessation. Haley is a minor living with her parents, and
education is needed on the triggering effects second hand smoke has on asthma.
QUESTION 3
Based on table 62.9 in your book and the infographic in the course on “The Things to Remember When
Treating Asthma”, how would you classify Haley’s asthma?
Answer:
Haley has moderate persistent asthma.
Haley's asthma can be classified as intermittent asthma related to the use of a SABA PRN for relief of her
asthma symptoms.
This study source was downloaded by 100000838928381 from CourseHero.com on 06-15-2022 09:17:18 GMT -05:00
https://www.coursehero.com/file/125880474/WEEK-5-ASTHMA-CASE-STUDYdocx/
QUESTION 2
The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by
NPs and other healthcare professionals and includes:
S: subjective information provided by the patient
O: objective information obtained by the provider
A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information
has already been provided to you in the case.
P: medical plan.
Write a brief SOAP note addressing Haley’s presentation to the clinic and chief complaint. Be sure to
include each component: SOAP. A reference is not required for this question.
Answer:
S:
"I can't stop coughing"
HPI: Haley, a 10-year old presents to the clinic accompanied by her parents complaining of a persistent
cough. She has a history of asthma and reports getting up 3-4 nights to use her albuterol inhaler, in
addition to this morning before the office visit. She experiences wheezing 3-4 times a week especially
when at the gym or in contact with a cat. Current medications include a SABA.
PMI: history of asthma, NKDA
Family Hx: Mother- asthma; Father- hypertension, current smoker; no siblings
Social Hx: well balanced diet with occasional fast food; gym at school and plays outside daily until
symptoms of asthma occur; doing well in school
Review of Systems:
General: No recent change of weight, no fever, chills, diaphoresis
Cardiovascular: Denies chest pain, palpations, edema, report dyspnea.
Respiratory: reports shortness of breath, wheezing, chest tightness, cough, denies hemoptysis
and pleurisy
HEENT: Denies headache, rhinorrhea, or sinus congestion
GI: denies constipation, diarrhea, and other stool abnormalities
GU: denies dysurea
Musculoskeletal: denies back/neck pain or weakness
Psychiatric: denies depression, anxiety, or suicidal ideations
O:
This study source was downloaded by 100000838928381 from CourseHero.com on 06-15-2022 09:17:18 GMT -05:00
https://www.coursehero.com/file/125880474/WEEK-5-ASTHMA-CASE-STUDYdocx/
, Vitals: T:98.2, RR:24. HR:118, BP108/64, SaO2:92%
Height: 56 inches Weight: 72 pounds BMI: 16.1
General: Alert and oriented to person, place, time, and situation, in slight respiratory
distress.
HEENT: PERRLA, no nasal flaring nasal polyps, no swelling of the lymph nodes.
Neck: no JVD, full ROM
Thorax: there is limited chest expansion with use of accessory muscles
Lungs: wheezing, diffuse wheezes bilaterally on expiration and occasionally on inspiration; presence of
breath sounds, decreased breath sounds bilaterally with tight air movement
Heart: Tachycardia with s1 and s2 regular rate and rhythm.
Neurological: cranial nerves intact
A:
Asthma
P:
Haley and her family need to be educated on asthma, its symptoms, and the use of an inhaler.
The patient and her family also need to demonstrate using the metered dose inhaler and spacers.
Haley and her father need to be educated on compliance with the medication regimen to reduce the risk
of asthma-related exacerbation, hospitalizations, and deaths.
The patient and her family need to be educated on the avoidance of triggering factors like pets.
A written asthma action plan needs to be provided with information on asthma, medication change,
including dose, route, and frequency.
Information needs to be provided on recognizing the worsening of symptoms and seeking medical help,
if needed, to Haley and her family.
Haley's father needs to be educated on smoking cessation. Haley is a minor living with her parents, and
education is needed on the triggering effects second hand smoke has on asthma.
QUESTION 3
Based on table 62.9 in your book and the infographic in the course on “The Things to Remember When
Treating Asthma”, how would you classify Haley’s asthma?
Answer:
Haley has moderate persistent asthma.
Haley's asthma can be classified as intermittent asthma related to the use of a SABA PRN for relief of her
asthma symptoms.
This study source was downloaded by 100000838928381 from CourseHero.com on 06-15-2022 09:17:18 GMT -05:00
https://www.coursehero.com/file/125880474/WEEK-5-ASTHMA-CASE-STUDYdocx/
