NR 565 Week 6 Asthma Case Study Q&A

NR 565 Week 6 Asthma Case Study Q&A QUESTION 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: 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