Tina Jones shadow health SOAP Note

SOAP Note Format

Patient Information:

Tina Jones is an obese 28-year-old African American female, who comes in today for evaluation and treatment of asthma exacerbation.

S.

CC (chief complaint)

“I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.”

HPI: include all the information regarding the CC using the OLDCART format.

Onset: 2 days ago

Location: Nose and lungs

Duration: 2 days

Characteristics: Chest feels tight and she has noticed some wheezing, with non-productive, dry cough

Aggravating Factors: Worse at night when she is lying down on her back.

Relieving Factors: Albuterol inhaler 3 puffs every four hours (however, does not feel like it is completely under control). Drinking water helps with the cough.

Treatment: Albuterol inhaler 3 puffs every four hours

Current Medications:

Albuterol 90 mcg/spray 3 puffs every four hours as needed for wheezing when around cats

Allergies:

Penicillin= rash

Cats and dust= runny nose, itchy and swollen eyes and increased asthma symptoms

Ms. Jones denies any food or latex allergies

PMHx:

Asthma diagnosed at age 2 ½

Last time hospitalized for asthma was when she was a little girl, has never been intubated

Type 2 Diabetes Mellitus diagnosed at age 24

Menarche at age 11

Sexually active with men only, last tested for STIs four years ago, never tested for HIV

Soc Hx:

Tine is a supervisor at Mid American Copy and Ship she has been working there since she was in high school. She is single and never been pregnant. Tine is a non-smoker and reports drinking alcohol socially with friends once a month. Reports the use of Marijuana from age 18 to 20. Tina is part of a book club and enjoys going to church talks. She currently lives with her mother and sister.

Fam Hx:

Tina reports her sister also has asthma. Denies any family history of COPD, or any throat or neck surgeries. Her mother is living and has high cholesterol and hypertension. Her father passed away in a car accident a year ago. Father had high cholesterol, hypertension and type 2 diabetes. Her bother is obese and her sister has asthma. Tina denies any family history of eczema or COPD.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional: Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe. You may focus the ROS to match the chief complaint unless you are doing a complete health history.

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Reports shortness of breath, chest tightening, wheezing and non-productive dry cough

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain.

GENITOURINARY:  No burning on urination, never been pregnant. Last menstrual period started yesterday.

NEUROLOGICAL:  No headache, No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: History of asthma, with allergy to cats, dust and penicillin.

O.

Physical exam: See above ROS.

Diagnostic results: None

A.

Differential Diagnoses

Asthma exacerbation

  1. No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention

Diagnostics:  

Order PFTs to be completed after exacerbation to have a baseline

Obtain oxygen saturation

 

 

Rx: list treatments and medications you will order and “continue previous meds” if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.

Tina would be started on corticosteroids such as Flovent (44mcg per actuation) 2-4 puffs inhaled bid

Continue with Albuterol inhaler as well.

Education: think about covering yourself legally; also indicate when written instructions are given.

 

Tine would be educated on the importance of seeing her asthma doctor regularly to manage and treat asthma symptoms.

 

Encourage her to keep a log of her asthma symptoms and triggers, and bring to her next visit for review.


Referral/Consults:

 

Ms. Jones would be referred to an Allergist for evaluation and treatment.

 

Follow up: indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

 

Follow up appointment would be in 2-4 weeks to review asthma log and make sure medications are helping.

 

Reference

Prieto Centurion, V., Huang, F., Naureckas, E. T., Camargo, C. J., Charbeneau, J., Joo, M. J., & … Krishnan, J. A. (2012). Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation. BMC Pulmonary Medicine, 1273. doi:10.1186/1471-2466-12-73. Retrieved from:

 

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