NR 565 Week 6 Asthma Case Study Q&A
QUESTION
The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of
documentation used by
NPs and
... [Show More] other healthcare professionals and includes:
S: subjective information provided by the patient
O: objective information obtained by the provider
A: assessment is the medical diagnosis rather than the physical assessment. *Hint,
this information has already been provided to you in the case.
P: medical plan.
Write a brief SOAP note addressing Haley’s presentation to the clinic and chief
complaint. Be sure to include each component: SOAP. A reference is not required for
this question.
Answer:
S:
"I can't stop coughing"
HPI: Haley, a 10-year old presents to the clinic accompanied by her parents
complaining of a persistent cough. She has a history of asthma and reports getting up 3-
4 nights to use her albuterol inhaler, in addition to this morning before the office visit.
She experiences wheezing 3-4 times a week especially when at the gym or in contact
with a cat. Current medications include a SABA.
PMI: history of asthma, NKDA
Family Hx: Mother- asthma; Father- hypertension, current smoker; no siblings
Social Hx: well balanced diet with occasional fast food; gym at school and plays outside
daily until symptoms of asthma occur; doing well in school
Review of Systems:
General: No recent change of weight, no fever, chills, diaphoresis
Cardiovascular: Denies chest pain, palpations, edema, report dyspnea.
Respiratory: reports shortness of breath, wheezing, chest tightness, cough, denies
hemoptysis and pleurisy
HEENT: Denies headache, rhinorrhea, or sinus congestion
GI: denies constipation, diarrhea, and other stool abnormalities
GU: denies dysurea
Musculoskeletal: denies back/neck pain or weakness
Psychiatric: denies depression, anxiety, or suicidal ideations
O:
Vitals: T:98.2, RR:24. HR:118, BP108/64, SaO2:92%
Height: 56 inches Weight: 72 pounds BMI: 16.1
General: Alert and oriented to person, place, time, and situation [Show Less]