S.O.A.P. Note CASE ID# 4 Tina Jones Respiratory
Subjectiv
e
Objectiv
e
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
omplaintChi
Asthma exacerbation
What brought you
here today (e.g.,
headache)
Chronological order of events, state of health before the onset of CC
Onset Ms. Jones is a 28-year-old female That presented to the clinic
Location today complaining of shortness of breath and wheezing. This
Duration began two days ago when she was at her cousin's house an
Character exposed to a cat, which is a known asthma trigger for her.
Aggravating/associated Another trigger for her asthma is dust. The patient reported
factors that she had severe wheezing and shortness of breath that
Relieving factors lasted five minutes. She denies any chest pain or other allergic
Temporal factors – symptoms. She used her albuterol inhaler to help alleviate
other symptoms, but the symptoms did not completely resolve. Since
things going on then, she has had ten episodes of wheezing with shortness of
breath around every four hours. Her last event of shortness of
History of Present
breath was yesterday morning, and she is also noticing that the
symptoms are worsened whenever she lies flat and has
Illness
increased movement. She also has a nonproductive cough and
is waking at night with shortness of breath roughly two times a
night. She says that her current symptoms are beginning to
interfere with her activities of daily living. She feels that she
Severity
needs something else to help with her asthma symptoms. She
is currently sitting upright on the exam table in no acute
distress. She was diagnosed with asthma at age 2. She has no
current exam results for spirometry or peak flow and does not
keep an asthma diary. She does not have a home nebulizer or
vaporizer machine. She has been hospitalized five times in her
life span for asthma exacerbations with the last hospital
admission at 16 years of age. She has never been intubated for
an asthma attack. Ms. Jones
reports that she does not currently see a pulmonologist or
allergist. The patient typically tries to avoid asthma triggers
when she can.
Adult Illnesses, The patient has a medical history of Type 2 diabetes, asthma
Past Medical
childhood illnesses, since a very young age, seasonal allergies, denies
History
immunizations, hypertension, and generalized anxiety. She states that she has
surgeries, allergies, had an allergy to penicillins
current medications from a very young age that gave her a rash and hives. The
patient is up- to-date with childhood immunizations. Ms. Jones
states that she has not
This study source was downloaded by 100000852114193 from CourseHero.com on 10-07-2022 00:25:52 GMT -05:00
https://www.coursehero.com/collection/62216714/AHA-SOAP-Typhon-4-Tina-Jones-Respiratorydocx/
Subjectiv
e
Objectiv
e
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
omplaintChi
Asthma exacerbation
What brought you
here today (e.g.,
headache)
Chronological order of events, state of health before the onset of CC
Onset Ms. Jones is a 28-year-old female That presented to the clinic
Location today complaining of shortness of breath and wheezing. This
Duration began two days ago when she was at her cousin's house an
Character exposed to a cat, which is a known asthma trigger for her.
Aggravating/associated Another trigger for her asthma is dust. The patient reported
factors that she had severe wheezing and shortness of breath that
Relieving factors lasted five minutes. She denies any chest pain or other allergic
Temporal factors – symptoms. She used her albuterol inhaler to help alleviate
other symptoms, but the symptoms did not completely resolve. Since
things going on then, she has had ten episodes of wheezing with shortness of
breath around every four hours. Her last event of shortness of
History of Present
breath was yesterday morning, and she is also noticing that the
symptoms are worsened whenever she lies flat and has
Illness
increased movement. She also has a nonproductive cough and
is waking at night with shortness of breath roughly two times a
night. She says that her current symptoms are beginning to
interfere with her activities of daily living. She feels that she
Severity
needs something else to help with her asthma symptoms. She
is currently sitting upright on the exam table in no acute
distress. She was diagnosed with asthma at age 2. She has no
current exam results for spirometry or peak flow and does not
keep an asthma diary. She does not have a home nebulizer or
vaporizer machine. She has been hospitalized five times in her
life span for asthma exacerbations with the last hospital
admission at 16 years of age. She has never been intubated for
an asthma attack. Ms. Jones
reports that she does not currently see a pulmonologist or
allergist. The patient typically tries to avoid asthma triggers
when she can.
Adult Illnesses, The patient has a medical history of Type 2 diabetes, asthma
Past Medical
childhood illnesses, since a very young age, seasonal allergies, denies
History
immunizations, hypertension, and generalized anxiety. She states that she has
surgeries, allergies, had an allergy to penicillins
current medications from a very young age that gave her a rash and hives. The
patient is up- to-date with childhood immunizations. Ms. Jones
states that she has not
This study source was downloaded by 100000852114193 from CourseHero.com on 10-07-2022 00:25:52 GMT -05:00
https://www.coursehero.com/collection/62216714/AHA-SOAP-Typhon-4-Tina-Jones-Respiratorydocx/
