Nursing Homework week 11

Asthma Exacerbation

Date of Encounter: 09/01/2025 Age/Sex: 29-year-old Female Race: Hispanic Insurance: PPO Referral: No referral Reason for Visit: New Consult Chief Complaint: Shortness of breath, wheezing, and cough for 2 days Type of H&P: Focused Type of Decision-Making: Moderate Time with Patient: 35 minutes Consult with Preceptor: 10 minutes

Social Problems Addressed: Education/Language, Safety Medications: Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days Adherence Issues: None reported

ICD-10 Codes:

· J45.901 – Unspecified asthma with (acute) exacerbation

CPT® Billing Codes:

· 99213 – Office/outpatient visit, established patient

Clinical Notes: Patient presents with SOB, wheezing, and cough for 2 days. O₂ sat 94%, scattered expiratory wheezes. Nebulized albuterol given in office with improvement. Prescribed short course of oral steroids and advised inhaler use every 4–6 hrs as needed. Patient educated on trigger avoidance and follow-up in 1 week.

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) - Pap smear: ______ - Mammogram: ______ - Colonoscopy: ______ - Lipid panel: ______ - A1C: ______ - STI screen: ______ - Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A - PHQ-9: ___ /27 - GAD-7: ___ /21 - AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states...”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): - CBC: - Lipid Panel: - A1C: - EKG: - Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: - [ ] None noted - [ ] Positive suicidal ideation - [ ] Unstable vital signs - [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

-

-

-

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· -

· -

Pharmacological treatment:

-

Non-Pharmacologic treatment:

Education (provide the most relevant ones - tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).