Asthma Exacerbation

SOAP NOTE: Asthma Exacerbation 3

 

Patient name: A.A

Sex: Female DOB: 9/04/1995 Age: 25 years-old

Ethnicity: Hispanic.

Language: Spanish.

Marital Status: Married

Religion: Christian

SUBJECTIVE:

Chief Complaint: “I can’t cash my breath since this morning when I finished my exercise routine at gym”

History of Present Illness: 

Patient is a 25-years-old that presents to the office with a chief complain of Shortness of breath, since this morning after finished workout at gym, patient with wheezing upon auscultation. Patient denied any other symptoms related.

Past Medical History:

Surgeries: N/A ( if any add it)

Hospitalizations: N/A if any add it

Chronic Medical conditions: Asthma as per records and patient statement.

Psychiatric Illnesses: None.

Injuries: None

Childhood Illnesses: Asthma since 5 years old.

Preventive Care:

Pap smear: 12/2019( Negative)

Family History: 

Mother is alive: Asthma

Father is alive: Cancer and Diabetes.

Sister is alive: Diabetes

Brother: No brother

Children: No Children

Additional History:

Immunizations: All vaccines current/ Flu vaccine: 9/15/2020

Nutritional Status: Regular Diet.

Physical Trauma/ Accident: Denied

BEHAVIOR/HABIT:

Caffeine: Yes

Smoke: No

Alcohol:No

Drug: No using illicit drugs

Exercises: Moderate exercise habit

Legal Document: Patient does not have a living will and livings will/advanced not directives on records.

FUNCTIONAL STATUS:

Normal/ Independent ADL’s.

Allergies: Not Known Drug Allergies. Or what the patient has.

 

Medications:  currently taking:

Albuterol 2.5 mg 3 or 4 times a day by nebulization, over approximately 5 to 15 minutes.

Advair Diskus 2 puff twice a day.

 

HEALTH CARE MAINTENANCEShe has received the influenza vaccine recently. Annual check up with primary care provider. Review of physical health, well being, and psychosocial concerns, nutritional education and guidance, and health education, guidance annually by patient chart.

OBJECTIVE: APPEARANCE: Well nourished, developed and dressed/groomed, pleasant demeanor, speech clear. Appears to be without discomfort, does not look distressed.

 

VITALS SIGNS:

-Blood Pressure: 100/58

-Pulse: 99 bpm

-Respiration: 24 rpm ) Not Regular)

-Temperature: 98.3 degrees Fahrenheit

-O2 saturation: 100% at room air.

-Weight: 130 lbs

-Height: 5’2”

-BMI: 22

-Pain level 0/10 on scale of pain. (If is a case with pain put scale from 0-10 and describe it) OLDCART Onset-Location-Duration-Characteristics-Aggravating-Factors-Relieving-FactoTreatment.

 

Respiratory: Shortness of breath, with rapid respiration, on auscultation wheezing through all

ASSESSMENT:

DIAGNOSIS:

Asthma exacerbation diagnosis due clinical presentation and physical exam.

1. Asthma exacerbation (ICD 10: J45.901).

Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible broncho constriction. Symptoms and signs include dyspnea, chest tightness, cough, and wheezing. The diagnosis is based on history, physical examination, and pulmonary function tests.

DIFFERENTIAL DIAGNOSTIC:

Wheezing is a relatively high-pitched whistling noise produced by movement of air through narrowed or compressed small airways. It is common in the first few years of life and is typically caused by viral respiratory tract infection or asthma, but other possible causes include inhaled irritants or allergens, esophageal reflux, and heart failure.

Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational exposures are less common causes in nonsmokers. Symptoms are productive cough and dyspnea that develop over years; common signs include decreased breath sounds, prolonged expiratory phase of respiration, and wheezing. Severe cases may be complicated by weight loss, pneumothorax, frequent acute decompensation episodes, right heart failure, and/or acute or chronic respiratory failure.

Hypersensitivity pneumonitis is a syndrome of cough, dyspnea, and fatigue caused by sensitization and subsequent hypersensitivity to environmental (frequently occupational) antigens. Acute, subacute, and chronic forms exist; all are characterized by acute interstitial inflammation and development of granulomas and fibrosis with long-term exposure.

Plan:

Lab test:Chest X-ray Posterior/Anterior and Lateral.

Pulse Oximetry.

Pharmacologic treatment: 1. Dry Powder Inhaler: 90 mcg/puff 2 puffs q 4–6 h as needed and 2 puffs 15–30 minutes before exercise.

2. Mometasone Dry Powder Inhaler: 110 or 220 mcg/puff 220 mcg once/day in the evening (maximum 220 mcg twice a day or 440 mcg once/day in the evening).

3. Prednisolone Short-course burst: 40–60 mg once/day (or 20–30 mg bid) for 3–10 days.

Non- Pharmacological Treatment:

1) Relaxation and breathing techniques such as yoga that help to prevent asthma symptoms and improve your overall wellbeing.

2) Continue with Regular physical activity, that help improving the performance of your heart and lungs.

3) Avoiding allergy triggers.

4) Not start smoking

Education Plans:

Increase intake of water. (2 liters/day).

High fiber diet (more than 30 g/day).

Patient educated on management of Asthma exacerbation in dietary measures and preventions of further complications of her new medications treatment, also to contact the provider if an abnormally or knew symptoms occurs.

Return to the Clinic after more Labs and Test was done to review results.

Follow-ups/Referrals: -Referrals to Pulmonologist for follow up and further treatments.

-Follow up in two weeks to evaluated patient and other laboratory testing results.

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