NURS 5465 Asthma Case study E.A 5 years old, Female University of Texas,
Arlington
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
E.A., 5 years old, Female, Grandma & mother reliable, DOB: ask the mother Mother: living,
the patient’s birthday smokes, How
much do you
smoke? Do you
have any past
medical history?
Father: living,
used albuterol as
a child,
Gma: living,
Grandma, do you
have any past
medical history?
Personal/Social
Hx:
Chief Complaint/RFE: Lives in house
Cough and difficulty breathing with mother,
father, &
grandma. Has a
dog, cat, & snake
all indoor. Active
child and enjoys
playing with
friends. Exposed
to secondhand
Hx Present Illness: (7 Variables but do not list as such) smoke.
Patient brought in for cough and difficulty breathing that was sudden onset without pain. Where do
you feel difficulty breathing? The duration of the symptoms started this morning after waking up.
Can you describe the difficulty breathing? Is it hard to take a big breath? The coughing is worse at
night and wakes the patient often. Coughing is observed by the family when the patient is playing
outdoors. Patient has had a runny nose and congestion for the last 5 days. The mother reports the
patient takes Zyrtec 5 or 10mg as needed for her runny nose. Has she been taking Zyrtec? When
was the last time she took the medication and what dose? Does anything make the difficulty
breathing better? Do you still have albuterol that you can use? Per mother patient had episodes of
shortness of breath in the past the last two years and was managed with Albuterol but not steroids.
The patient colds tend to last longer than other children. The patient has a noticeable rash on arms
and behind the knees that has been previously treated with hydrocortisone cream per grandma.
CURRENT HEALTH
Medications: Zyrtec 5mg or 10mg PRN
Allergies: NKDA
Last PE & Screenings: Not provided. When was the child’s last physical? Were there any
abnormalities?
Immunization Status: Up to date, Did she get the flu shot this year?
LMP & Birth Control (if applicable) : Not applicable
PMH
Illnesses & Trauma: recurrent wheezing, denies trauma. When was the last time she was wheezing?
, Hospitalizations/Surgeries: 38 weeks vaginal delivery, Denies surgeries. Previous 5 ED visits for SOB
managed
with albuterol within the last 2 years. When was the last ED visit for SOB?
OB Hx/Sexual Hx: Not applicable
Emotional/Psy Hx: deferred at this time.
REVIEW OF SYSTEMS
General: Any fevers or chills? Has she been more tired or sleepy?
Nutrition: Any changes in diet? Still eating and drinking fluids?
Skin/Hair/Nails: dry, red, itchy patches on arms and behind knees.
HEENT: reports cough worse at night and noticeable when outside playing, A runny nose and
congestion for 5 days, denies sore throat. Any ear pain, watery eyes, bloody nose, or sputum?
Breasts Deferred
Respiratory: reports difficulty breathing, Any wheezing, chest tightness or shortness of breath?
CV/peripheral vascular: denies heartburn, Any pain in the chest?
GI :denies vomiting, Any stomach pain, diarrhea, or constipation?
GU: Deferred
MSK : Deferred
Psych : Deferred
Neuro : Deferred
Lymph/Heme/Endocrine: Any swelling around the neck or noticeable bumps?
O/ Physical Exam: T: not provided P: 100 R: 22 O2 92% BP: Not provided HT: Not provided, Obtain
a height on the patient WT: 45 lbs BMI: Need HT to calculate.
General : Afebrile, Does the patient interact? Is she able to speak full sentences or only words? Is
she leaning forward in a tripod position?
Skin : Keratotic slightly raised patches to the AC and posterior popliteal,
Head : Deferred
EENT : Non-productive cough, clear runny nose with boggy turbinates, normal voice, normal dental
eruption without dental carries, Are the turbinates pink or pale in color? Does the pharynx appear
Neck : supple neck with full ROM,
Breasts/Chest : Moderate accessory muscle use without retractions,
Lungs: audible wheezing, expiratory wheezes throughout with an increased expiratory phase, good
air flow with diminished breath sounds bilaterally in the lower lobes
Heart/ perip vascular: Radial and Femoral pulses +2 bilaterally, Are heart sounds normal?
Abdomen : scaphoid abdomen with active BS, nontender without masses or
hepatosplenomegaly,
Genitalia/Rectum : Deferred
Lymph : no palpable lymph nodes,
MSK : Deferred
Neuro : Deferred
A/ Medical Dx: (Max of 2 – Give ICD 10) Rule Outs (only if applicable):
• Mild persistent asthma with Health Profile:
exacerbation J45.31 age/gender/racial risks: Asthma,
(ICD10Data, 2024a)
• Allergic Rhinitis J30.89
(ICD10Data, 2024b)
Pertinent Positives:
• Audible and Expiratory wheezing personal/family: Father used albuterol as a child,
screening needs:
• Boggy turbinates Ophthalmology
• Diminished breath sounds visit Dentist visit
• Increased expiratory phase Allergy testing
• Cough worse during the
night and waking up
• Rhinorrhea
• Lives with pets
• Secondhand smoke exposure
Pertinent Negatives: counseling needs: Wearing helmet riding a bike, dietary
needs,
Arlington
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
E.A., 5 years old, Female, Grandma & mother reliable, DOB: ask the mother Mother: living,
the patient’s birthday smokes, How
much do you
smoke? Do you
have any past
medical history?
Father: living,
used albuterol as
a child,
Gma: living,
Grandma, do you
have any past
medical history?
Personal/Social
Hx:
Chief Complaint/RFE: Lives in house
Cough and difficulty breathing with mother,
father, &
grandma. Has a
dog, cat, & snake
all indoor. Active
child and enjoys
playing with
friends. Exposed
to secondhand
Hx Present Illness: (7 Variables but do not list as such) smoke.
Patient brought in for cough and difficulty breathing that was sudden onset without pain. Where do
you feel difficulty breathing? The duration of the symptoms started this morning after waking up.
Can you describe the difficulty breathing? Is it hard to take a big breath? The coughing is worse at
night and wakes the patient often. Coughing is observed by the family when the patient is playing
outdoors. Patient has had a runny nose and congestion for the last 5 days. The mother reports the
patient takes Zyrtec 5 or 10mg as needed for her runny nose. Has she been taking Zyrtec? When
was the last time she took the medication and what dose? Does anything make the difficulty
breathing better? Do you still have albuterol that you can use? Per mother patient had episodes of
shortness of breath in the past the last two years and was managed with Albuterol but not steroids.
The patient colds tend to last longer than other children. The patient has a noticeable rash on arms
and behind the knees that has been previously treated with hydrocortisone cream per grandma.
CURRENT HEALTH
Medications: Zyrtec 5mg or 10mg PRN
Allergies: NKDA
Last PE & Screenings: Not provided. When was the child’s last physical? Were there any
abnormalities?
Immunization Status: Up to date, Did she get the flu shot this year?
LMP & Birth Control (if applicable) : Not applicable
PMH
Illnesses & Trauma: recurrent wheezing, denies trauma. When was the last time she was wheezing?
, Hospitalizations/Surgeries: 38 weeks vaginal delivery, Denies surgeries. Previous 5 ED visits for SOB
managed
with albuterol within the last 2 years. When was the last ED visit for SOB?
OB Hx/Sexual Hx: Not applicable
Emotional/Psy Hx: deferred at this time.
REVIEW OF SYSTEMS
General: Any fevers or chills? Has she been more tired or sleepy?
Nutrition: Any changes in diet? Still eating and drinking fluids?
Skin/Hair/Nails: dry, red, itchy patches on arms and behind knees.
HEENT: reports cough worse at night and noticeable when outside playing, A runny nose and
congestion for 5 days, denies sore throat. Any ear pain, watery eyes, bloody nose, or sputum?
Breasts Deferred
Respiratory: reports difficulty breathing, Any wheezing, chest tightness or shortness of breath?
CV/peripheral vascular: denies heartburn, Any pain in the chest?
GI :denies vomiting, Any stomach pain, diarrhea, or constipation?
GU: Deferred
MSK : Deferred
Psych : Deferred
Neuro : Deferred
Lymph/Heme/Endocrine: Any swelling around the neck or noticeable bumps?
O/ Physical Exam: T: not provided P: 100 R: 22 O2 92% BP: Not provided HT: Not provided, Obtain
a height on the patient WT: 45 lbs BMI: Need HT to calculate.
General : Afebrile, Does the patient interact? Is she able to speak full sentences or only words? Is
she leaning forward in a tripod position?
Skin : Keratotic slightly raised patches to the AC and posterior popliteal,
Head : Deferred
EENT : Non-productive cough, clear runny nose with boggy turbinates, normal voice, normal dental
eruption without dental carries, Are the turbinates pink or pale in color? Does the pharynx appear
Neck : supple neck with full ROM,
Breasts/Chest : Moderate accessory muscle use without retractions,
Lungs: audible wheezing, expiratory wheezes throughout with an increased expiratory phase, good
air flow with diminished breath sounds bilaterally in the lower lobes
Heart/ perip vascular: Radial and Femoral pulses +2 bilaterally, Are heart sounds normal?
Abdomen : scaphoid abdomen with active BS, nontender without masses or
hepatosplenomegaly,
Genitalia/Rectum : Deferred
Lymph : no palpable lymph nodes,
MSK : Deferred
Neuro : Deferred
A/ Medical Dx: (Max of 2 – Give ICD 10) Rule Outs (only if applicable):
• Mild persistent asthma with Health Profile:
exacerbation J45.31 age/gender/racial risks: Asthma,
(ICD10Data, 2024a)
• Allergic Rhinitis J30.89
(ICD10Data, 2024b)
Pertinent Positives:
• Audible and Expiratory wheezing personal/family: Father used albuterol as a child,
screening needs:
• Boggy turbinates Ophthalmology
• Diminished breath sounds visit Dentist visit
• Increased expiratory phase Allergy testing
• Cough worse during the
night and waking up
• Rhinorrhea
• Lives with pets
• Secondhand smoke exposure
Pertinent Negatives: counseling needs: Wearing helmet riding a bike, dietary
needs,
