SOAP for a Patient with Respiratory Illness
Problem List
Active problems: labored breathing, wheezing, shortness of breath
Inactive problems: trouble with normal daily activities, discomfort
Risk factors: history of asthmatic attack at age 16, positive history of asthma in the family, history of smoking marijuana for five years, exposure to allergens. She denies history of bronchitis, pneumonia or emphysema. She was diagnosed with asthma when 3 years old and reports to not seeing an asthma specialist within the last two years. She has had five previous hospitalizations for asthma, with the most recent being at age 18 years. The hospital treatment during her admission was steroids and a nebulizer. She reports being allergic to cats, with subsequent symptoms of itchy eyes, sneezing and wheezing following exposure to the allergen. She also reports to avoiding cats when possible, using inhaler often and showering frequently. Regarding marijuana, she affirms having smoked marijuana six to seven years ago after smoking for five to six years. She reports not being exposed to secondary smoke.
Subjective Data
Miss T.J. is a 28-year-old African American female with a pleasant personality. She presented to the clinic with complaints of shortness of breathing that has been going on for the last two days. Her last menstrual period was a week ago, on 6th February, 2021. Miss T.J. reported that she had been increasingly using her inhaler than the usual, and had been using more than the prescribed. She reported that the inhaler was unhelpful in relieving her symptoms. She reported presence of chest tightness but without chest pain. Miss T.J. also reported recent exposure to a cat, after which she developed the breathing problems (Gautier & Charpin, 2017). She suspected close contact to the cat triggered her complications. She also reports she is experiencing dry cough.
Review of Systems: Denies chest pain, weight loss or gain, fatigue, weakness. Denies sputum on her cough. Denies COPD, eczema or any other lung problem besides asthma.
Family History: Her sister has a history of asthma, but she is doing fine. There is no family history of other respiratory illnesses. She denies history of tobacco use in the family. Also denies history of lung cancer.
Social History: Denies any exposure to irritants at work. Denies smoking cigarettes. Reported history of smoking marijuana. Denies using illicit drugs.
Objective Data
Miss T.J. is pleasant, is not in acute respiratory distress, is alert and well-oriented in time, place and person. She maintains eye contact during the interview and examination.
Her chest is symmetric, without visible chest-wall deformities. The chest expansion is equal, bilaterally while the tactile vocal fremitus is as expected and equal bilaterally. On percussion, both sides are resonant, without any area of dullness. During auscultation, breath sounds are present in all areas. There is wheezing in the posterior lobes, bilaterally. Her oxygen saturation levels are at 96 %. The spirometry revealed forced vital capacity (FVC) of 3.92 L and a forced expiratory volume (FEV1) of 3.14.
History of Presenting Illness
Miss T.J. is a pleasant 28-year-old African American lady who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She also reports she was at her grandmother’s place where she was exposed to cats that triggered her asthma symptoms. The character of her asthma was intermittent, with exacerbations of up to 2 times per week. At the time of the incidence, she noted her wheezes had a severity of 6/10 while the shortness of breath had a severity of 7 to 8/10 and lasted six minutes. She did not have any allergic symptoms or chest pains.
Following the asthma attack, she utilized her albuterol inhaler, which resulted in her symptoms decreasing without completely resolving. She reports that since the current incident ensued she had 12 episodes of wheezing and had shortness of breath almost every 3 hours. Her final episode of shortness of breath was this morning before she came to the clinic. She remarks that the symptoms are worsened by movements and lying flat and relieved partly by her inhaler. All associations she reports are chest-tightness, wheezing, and shortness of breath. The night-time shortness of breath results in her awakening thrice per night. There is no associated coughing, no chest-pain and no painful breathing. However, she reports coughing when having a cold; the cough is non-productive and does not contain blood.
She is concerned that her symptoms are interfering with her daily activities and that her albuterol inhaler seems to be less effective than before in managing her condition. While the recommended inhaler dosage is between 1 and 3 puffs, she takes 2 puffs, at times 3 puffs to control the symptoms. The last usage of the inhaler was three days ago, and she has used it no more than twice per week. She reports her breathing at present is normal.
She was diagnosed with asthma when she was 2.5 years old. She does not recall a recent application of spirometry, does not utilize a peak flow and has neither a home nebulizer nor vaporizer. She has had seven hospital admissions following asthma, the final one at age 18. She has never been intubated for asthma and she has no present pulmonale or allergies.
Past Medical History:
Childhood illnesses: she denies history of measles, rubella, mumps, pertussis/whooping cough, chicken pox, rheumatic fever, scarlet fever, polio and other chronic childhood diseases.
Adult illnesses: she denies medical illnesses such as hepatitis, diabetes and hypertension. She is HIV negative. This is her sixth hospital admission following an asthma exacerbation. Her last hospital admission was at 18 years. She underwent surgery for bilateral tubal ligation at 24 years. She has had no history of blood transfusion.
Obstetric History, Gynecological History and Sexual History: Her last menstrual period was a week ago on 6th February, 2021. She has had no pregnancies, no births and no miscarriages. Her menarche was at 13 years and she reports to experience regular cycle lasting 28 days with normal flow that lasts 4 to 5 days, during which she uses 2 sanitary pads per day. There is no pathological bleeding in between her menses. She underwent voluntary surgical contraception (bilateral tubal ligation) at 24 years. She is heterosexual and has had two sexual partners who are both heterosexual males. She reports practicing safe sex with the partners. SOAP for a Patient with Respiratory Illness
She has no psychiatric illnesses and is not on any maintenance immunizations.
She had an elective mammogram on 24th August, 2020 whose results were normal breast tissue. She took a blood lipid profile on 21st January, 2021, which revealed minute elevations of low-density lipoprotein and slight elevation of triglycerides. The high density lipoprotein was normal.
Social History:
Miss T.J. is unaware of any environmental exposures to irritants at her home or workplace. She changes her sheets twice per week and denies presence of mildew or dust at her home. Her pillow cover is hypoallergic while her mattress is six months old. She denies current use of alcohol, tobacco or illicit drugs. She also denies history of smoking tobacco or vaping. While she smoked marijuana for five years, her last instance was at 21 years of age. She does not engage in physical exercise.
Review of Systems:
General: there is no weight changes, weakness, fatigue, chills, fever or night sweats.
Nose/sinuses: there is no rhinorrhea in the present episode, no sneezing, stuffiness, itching, sinus pressure, epistaxis or previous allergy.
Gastrointestinal: there is no nausea, no vomiting, no change in appetite, no abdominal pain, no GERD symptoms.
Respiratory: there is cough, shortness of breath and difficulty in breathing. There is no sputum, pneumonia, hemoptysis, bronchitis, emphysema or tuberculosis. She has a history of asthma in which her last hospital admission was at 18 years. Her last chest x ray was at 18 years.
Assessment
General Examination:
Miss T.J. is a pleasant, moderately overweight 29-year-old African American woman who is not in acute respiratory distress. She is alert and oriented in person, time and place while sitting upright at the examination table. She maintains appropriate eye contact throughout the interview and examination. There is no finger-clubbing, no central or peripheral cyanosis, no palmar erythema, no palmar palor, buccal palor, lingual palor or conjunctival palor. There is no dehydration.
Respiratory Exam:
There are no visible chest wall deformities and no surgical scars. The chest expansion is symmetrical bilaterally, while the chest moves with respiration equally on both sides. The chest is warm on touch and there are no palpable masses and no areas of tenderness. The trachea is centrally placed and the tactile vocal fremitus is present and normal. On percussion, the chest was resonant on both sides and there were no areas of dullness. Auscultation revealed bilateral expiratory wheezes in the posterior lower lobes. Breath sounds were present bilaterally and were neither increased nor reduced. There were bilateral muffled words with notable expiratory wheezes in the posterior lower lobes. There were no crackles. The forced vital capacity was 3.92 L, FEV1 was 3.14 while FEV1: FVC ratio was 80.10%. The percentage oxygen saturation was 96%.
Assessment diagnosis: asthma exacerbation
Plan
Educate Miss T.J. to take in plenty of water and fluids.
Check the oxygen saturation rates for baseline (Al-Shamrani et al., 2019).
Continue monitoring the symptoms and make a diary to log in asthma attacks while noting the triggers (Ramsahai, Hansbro & Wark, 2019).
Educate her to avoid triggers such as dust, cats, rabbits, dogs or other pets with fur (Gautier & Charpin, 2017).
Advise her to ensure her furniture, utensils, beddings and entire home is free from dust and dust mite.
Educate her to seek instantaneous medical attention in case she develops shortness of breath, the shortness of breath increases or the wheezing and asthma worsen. Advice the patient to continue using her inhaler as per the prescription (Albertson et al., 2020). In particular, she should seek medical attention immediately she experiences episodes of chest pain or shortness of breath that is not relieved by rest, worsening asthma symptoms or wheezing (Ramsahai, Hansbro & Wark, 2019). She should also seek medical attention in case she suspects her medication is unhelpful.
Advise her to take anti-allergic medication if required to help with the allergies (Ramsahai, Hansbro & Wark, 2019).
To come back within 2 to 3 weeks for clinical follow-up and evaluation of her prognosis.
Encourage her to continue monitoring the symptoms while login into her diary the episodes of asthma symptoms and wheezing with the relevant associations and bring the log on the next clinical visit (McCracken et al., 2017 SOAP for a Patient with Respiratory Illness).
Perform pulmonary function tests after the exacerbation to attain a baseline for comparison in future (Ramsahai, Hansbro & Wark, 2019).
Encourage the patient to wash beddings, furniture covers and other surfaces to eliminate dust and dust mites to reduce the likelihood for developing allergic symptoms at night (Gautier & Charpin, 2017).
Advise her to engage in recommended amounts of physical activity while eating low-calorie foods and meals with monounsaturated fats and essential fatty acids such as omega-3 and omega-6 fatty acids (Sikand et al., 2018). Exercise and low-fat diets plus healthy fats would result in decrease in the serum triglycerides and low-density lipoprotein that increase risks for inflammatory reactions and obesity.
SOAP for a Patient with Respiratory Illness References
Albertson, T. E., Chenoweth, J. A., Pearson, S. J., & Murin, S. (2020). The pharmacological management of asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS). Expert Opinion on Pharmacotherapy, 21(2), 213-231. https://doi.org/10.1080/14656566.2019.1701656
Al-Shamrani, A., Al-Harbi, A. S., Bagais, K., Alenazi, A., & Alqwaiee, M. (2019). Management of asthma exacerbation in the emergency departments. International journal of pediatrics & Adolescent Medicine, 6(2), 61. https://dx.doi.org/10.1016%2Fj.ijpam.2019.02.001
Gautier, C., & Charpin, D. (2017). Environmental triggers and avoidance in the management of asthma. Journal of Asthma and Allergy, 10, 47. https://doi.org/10.2147/jaa.s121276
McCracken, J. L., Veeranki, S. P., Ameredes, B. T., & Calhoun, W. J. (2017). Diagnosis and management of asthma in adults: a review. JAMA, 318(3), 279-290. https://doi.org/10.1001/jama.2017.8372
Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423-432. https://www.atsjournals.org/journal/ajrcmb
Sikand, G., Cole, R. E., Handu, D., deWaal, D., Christaldi, J., Johnson, E. Q., Arpino, L. M. & Ekvall, S. M. (2018). Clinical and cost benefits of medical nutrition therapy by registered dietitian nutritionists for management of dyslipidemia: A systematic review and meta-analysis. Journal of Clinical Lipidology, 12(5), 1113-1122. https://doi.org/10.1016/j.jacl.2018.06.016