Respiratory Diseases

                         Provide a SOAP evaluation for the Respiratory case.       

Case Information:
CC: “My asthma is acting up and I have missed too much school.” HPI: BK is a 19-year-old female who presents to the student health clinic complaining of increased SOB, wheezing, poor exercise tolerance, and a head cold for 4 days. She has started taking acetaminophen/aspirin/caffeine (Excedrin Migraine®) recently for headaches. PMH: Moderate persistent asthma for 12 years Perennial allergic rhinitis FH: Both parents living; mother 52 years old with HTN; father 58 years old with COPD (1 pack per day habit); one sibling age 23 in good health SH: no alcohol or tobacco use. Patient is a college sophomore history major and lives in a dormitory with her non-smoking roommate. Her boyfriend has a cat in his apartment.
Medications: Albuterol (Proventil®) HFA 2 puffs every 6 hours PRN Fluticasone (Flovent®) HFA 44mcg one puff BID Acetaminophen/aspirin/caffeine (Excedrin Migraine®) 1 tablet PRN headaches Ortho Novum 7/7/7 1 po QD Allergies: Aspirin (wheezing) Cats (wheezing) ROS: Unremarkable except for nasal stuffiness. Patient also reports that she wakes up at least twice a week with SOB and wheezing, and occasionally feels chest tightness in the morning. Physical Exam: GEN: Caucasian female in apparent distress with audible wheezing. VS: BP 118/78, HR 95, RR 28, T 98.6, wt 125lb, ht 5’6” CHEST: diffuse wheezes bilaterally on exhalation and occasionally on inspiration CV: regular rhythm; NMRG Labs (non-fasting): Na 137 K 4.4 Cl 102 HCO3 26 BUN 18 SCr 0.7 BS 104 Hgb 14 Hct 40 Plt 220 WBC 5.0 Peak Flow: 200 L/min (baseline 340 L/min).
Important considerations for creating a SOAP note:

  1. What two or three major problems can you identify with this patient?
  2. What subjective/objective information in the case supports each of those problems? Please list only information that pertains to each problem under each problem.
  3. What is your assessment and plan for each problem?
    a. Provide pharmacological and nonpharmacological care (don’t forget to be specific). Will you discontinue any medication that the patient is currently taking and/or add any new medications?
    b. Include your therapeutic goals for each problem (use the subjective and objective information listed above to help you)
    c. How will you monitor each problem and each medication included in your plan?
    d. When will you suggest following up with the patient?
    e. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?
    f. What educational information regarding disease and or medication does the patient need?

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