Health assessment assignment
rosario08
advhealthassessmentweek2soapassessment.docx
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
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Initials: J, T |
Age: 28 |
Gender: Female |
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Height |
Weight |
BP |
HR |
RR |
Temp |
SPO2 |
Pain Rating |
Allergies (Penicillin/ hives and rash) |
| 170 cm | 89 Kg | 140/82 | 89 | 20 | 98.5 | 97 |
Choose an item. |
Medication: Proventil( Albuterol inhaler) 90 mcg Q12 or PRN for asthma, Advil 200 mg TID PRN for menstrual cramps Food: NKA Environment: dust and cats |
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History of Present Illness (HPI) |
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Chief Complaint (CC) | “ I have been having breathing problems and my inhaler is just not working the way it normally does” |
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom |
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O nset |
Two days ago |
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L ocation | chest |
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D uration | Intermittent SOB |
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C haracteristics | Wheezing, Chest tightness, SOB, pain with breathing, |
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A ggravating Factors | Sleeping at night, when lying flat on back, movement, when albuterol weans off |
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R elieving Factors | Proventil puffs (albuterol) 90 mcg and drinking water |
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T reatment | Proventil( Albuterol Sulfate Inhalation Aerosol) 90 mcg 2 inhalation Q12 |
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Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. |
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Medication (Rx, OTC, or Homeopathic) |
Dosage |
Frequency |
Length of Time Used |
Reason for Use |
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| Albuterol Inhaler | 90 mcg | Q 12 and PRN | Since she was little , only take albuterol when it is needed | Asthma | ||||
| Tylenol | 50 mg ( pt is taking 100 mg TID) | TID |
2 days ago | For moderate pain | ||||
| Advil | 200 | PRN | Click or tap here to enter text. | For menstrual cramps | ||||
| Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | ||||
| Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | Click or tap here to enter text. | ||||
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
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Estimates 5 hospitalization for asthma Recent hospitalization to ER for wound injury in right foot No hx of surgeries |
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Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. |
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Pt currently working and has medical insurance Pt enjoyed going out with her friends, church activities and reading Pt reported general low activity level. Pt is diabetic in noncompliance with diabetes medication Patient drink alcohol one or two drink per week or less. Pt denied smoking and pt used to smoke marihuana in the past when she was 20 or 21 years old Pt denied use of tobacco or shewing tobacco.
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Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. |
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Pt family hx of HTN, Hyperlipidemia, Asthma, and Diabetes type II and Colon Cancer.
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Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. |
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Constitutional If patient denies all symptoms for this system, check here: ☐ |
Skin If patient denies all symptoms for this system, check here: ☐ |
HEENT If patient denies all symptoms for this system, check here: ☒ |
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☒Fatigue ☐Weakness Click or tap here to enter text. ☐Fever/Chills pt is experiencing chills and fever ☐Weight Gain NKA ☐Weight Loss pt claimed that she has loss weight ☐Trouble Sleeping NKA ☐Night Sweats pt wakes up hot at night ☐Other: Click or tap here to enter text. |
☐Itching Click or tap here to enter text. ☐Rashes ☐Nail Changes NKA ☒Skin Color Changes skin pigmentation changes in the neck and face ☐Other: Click or tap here to enter text.
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☐Diplopia NKA ☐Eye Pain complain of eye pain when reading but it could be related to HTN ☐Eye redness only when she is having allergies around cats ☐Vision changes NKA ☐Photophobia NKA ☐Eye discharge |
☐Earache NKA ☐Tinnitus NKA ☐Epistaxis NKA ☐Vertigo NKA ☐Hearing Changes NKA
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☐Hoarseness NKA ☐Oral Ulcers NKA ☐Congestion NKA ☐Rhinorrhea NKA ☐Other: Click or tap here to enter text.
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Respiratory If patient denies all symptoms for this system, check here: ☐ |
Neuro If patient denies all symptoms for this system, check here: ☐ |
Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☐ |
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Cough x Hemoptysis NKA Dyspnea x Wheezing: x Pain with Inspirations x |
☐Syncope or Lightheadedness NKA ☒Headache it could be related to deterioration with diabetes in vision or HTN ☐Numbness NKA ☐Tingling NKA ☐Sensation Changes Choose an item. ☐Speech Deficits NKA ☐Other: Click or tap here to enter text.
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☐Chest pain NKA ☒SOB with exertion ☒Exercise Intolerance Click or tap here to enter text. ☐Orthopnea NKA ☐Edema swelling in the right foot ☐Murmurs NKA
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☐Palpitations NKA ☐Faintness NKA ☐Claudications NKA ☒PND possible pt is HTN and diabetes type 2, no dx of PNA yet but has the risk factors ☐Other: Click or tap here to enter text.
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MSK If patient denies all symptoms for this system, check here: ☐
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GI If patient denies all symptoms for this system, check here: ☐ |
GU If patient denies all symptoms for this system, check here: ☒ |
PSYCH If patient denies all symptoms for this system, check here: ☐ |
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Pain : X (when breathing ) Stiffness NKA Swelling Redness NKA Misalignment NKA Other
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☐Nausea/Vomiting NKA ☐Dysphasia NKA ☐Diarrhea NKA Appetite change NKA ☐Blood in Stool NKA ☐Abdominal Pain NKA ☐Excessive Flatus NKA ☐Food Intolerance NKA ☐Rectal Bleeding NKA ☐Other:NKA
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☐Urgency NKA ☐Dysuria NKA ☐Burning NKA ☐Hematuria NKA ☐Polyuria nocturia ☐Nocturia ☐Incontinence nka ☐Other: nka
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☐Stress during busy and long days at work ☐Anxiety nka ☒Depression only when father passed away but no currently ☐Suicidal/Homicidal Ideation pt denied any suicidal thoughts ☐Memory Deficits ☐Mood Changes Click or tap here to enter text.☐Other: Click or tap here to enter text. |
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GYN If patient denies all symptoms for this system, check here: ☒ |
Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ |
Endocrine If patient denies all symptoms for this system, check here: ☒ |
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☐Rash only with penicillin adverse effects ☐Discharge Click or tap here to enter text. ☐Itching ☐Irregular ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☒LMP: 2 weeks ago ☐Contraception pt denied taking any, no sexually active, had a boyfriend but broke up
☐Other:NKA
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☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding ☐ Past Transfusions ☐ Enlarged/Tender lymph node(s) NKA ☐ Blood or lymph disorder pt denied any ☐ Other NKA
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☐ Abnormal growth ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☒ Diabetes ☒ Other possible HTN, allergies
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O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.
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Body System |
Positive Findings
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Negative Findings |
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General
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Unable to Assess |
Click or tap here to enter text. |
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Skin
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Skin is clean, dry and Intact, no open wounds, negative for cyanosis, discoloration of skin pigmentation in neck and face |
Click or tap here to enter text. |
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HEENT
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Unable to Assess
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Click or tap here to enter text. |
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Respiratory
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Oxygen saturation 97%, respirations:20, equally symmetric in chest expansion no evidence of abnormal findings Equally bilaterally expected fremitus All quadrants in the chest anteriorly and posteriorly are resonant, FVC 3.91 and FEV 3.15 |
Adventitious sounds, wheezing in posterior right lower lobe and posterior left lower lobe Pt reported chest tightness, increasing in breathing difficulties, increasing in SOB with movement and at night, chest pain when breathing. Pt reported cough Click or tap here to enter text. |
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Neuro
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A&Ox 4, unable to assess |
Click or tap here to enter text. |
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Cardiovascular
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Unable to Assess Click or tap here to enter text. |
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Musculoskeletal
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unable to assess |
Click or tap here to enter text. |
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Gastrointestinal
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unable to assess |
Click or tap here to enter text. |
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Genitourinary
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Unable to assess |
Click or tap here to enter text. |
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Psychiatric
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Unable to assess Unable to assess |
Click or tap here to enter text. |
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Gynecological
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Unable to assess |
Click or tap here to enter text. |
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Problem List |
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| Asthma Attack |
6. Click or tap here to enter text. |
11. Click or tap here to enter text. |
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2. cough |
7. Click or tap here to enter text. |
12. Click or tap here to enter text. |
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3. noncompliance to medication regimen |
8. Click or tap here to enter text. |
13. Click or tap here to enter text. |
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4. Uncontrolled diabetes type 2 |
9. Click or tap here to enter text. |
14. Click or tap here to enter text. |
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5. |
10. Click or tap here to enter text. |
15. Click or tap here to enter text. |
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
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Diagnosis |
ICD-10 Code |
Pertinent Findings |
| Moderate Persistent Asthma | ICD-10 J45.4x | SOB, adventitious sounds (wheezing in posterior BLL) |
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Noncompliance with medication regimen |
ICD Z91.14 |
Pt in no longer taking his DM 2 medications No properly use of albuterol with an spacer to effectively absorb medication Noncompliance of follow up of care for both chronic conditions
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| Cough Variant Asthma | . ICD 10 J45.991 | Persistent cough that increases at night |
| Diabetes type 2 mellitus with hyperglycemia | ICD 10 E11.65 | Pt diagnosed with diabetes type II in the past. Blood sugar of 224. Pt is not in compliance of diabetic medications. Furthermore, t has a family hx of diabetes too. . |
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
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Diagnostics: List tests you will order this visit |
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Test |
Rationale/Citation |
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| ABG, blood count, pulmonary function, oxygen saturation Chest x-ray, allergy skin testing, | ABG: it is important because it can reveals decreased in PO2, suggesting mild respiratory alkalosis Blood count: can reveal eosinophil count elevated Pulmonary Function: it is important because it can reveals increase in in residual volume, decrease in vital capacity, decreased in forced expiratory volume, and peak expiratory flow. Oxygen saturation: it is of significant importance because it can reveal low oxygen level specially when pt is having an asthma attach Chest x ray: this test important tool when treating and diagnosis asthmatic patient because it allows the physician to ruled out other condition such as pneumonia, bronchitis or even TB. Additionally; it reveals the location of the asthma exacerbation (air trapping extend or the inflammation extend). Allergy Skin Testing can help to determine patient allergies and asthma triggers; especially if patient asthma is a chronic condition and pt will be receiving long-term treatment. Furthermore, because the clinical finding of this test would help pt to manage better her asthma. | ||
| Diabetes | Accu checks TID and resume metformin. However, no additionally diagnostic testing ( None at this time) | ||
| Click or tap here to enter text. | Click or tap here to enter text. | ||
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Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. |
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Drug |
Dosage |
Length of Treatment |
Rationale/Citation |
| Proventil ( Albuterol Sulfate Inhalation Aerosol) | 90mcg , one puff Q12 | During asthma exacerbation | Albuterol is a recue medication and it should be use only during asthma exacerbation to open the airways and help pt to breath |
| Metformin | 500 mg PO daily | Continuously for diabetes | For better management of blood sugar levels, In particular if pt will be in steroid for asthma exacerbations. |
| Cetirizine HCL | 10 mg PO daily |
Continuously for allergies | To help pt to manage her allergies and prevent of asthma symptoms. |
| Prednisone |
15 ml PO daily | For 5 days | To control symptoms associate with asthma such as wheezing and improve breathing. |
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| Click or tap here to enter text. | Click or tap here to enter text. |
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Referral/Consults: |
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Allergist, Pulmonary, Follow up in 6 days to the clinic once pt completed 5 days steroids regimen |
Rationale/Citation | Click or tap here to enter text. | |
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Education: |
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Pt needs a lot of education in regards the proper use of albuterol with an spacer. Additionally, education in regards compliance to regimen to both of her chronic conditions such as asthma and diabetes. In the same manner more autonomy to her care and better understanding of management of her symptoms and triggers and predisposing factors that put her a risk to further conditions and illness,. |
Rationale/Citation | Click or tap here to enter text. | |
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Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere. |
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Pulmonologist/ Asthma Doctor/ Allergist Endocrinologist / Diabetes Management
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It is essential because pt requires additional education, guidance and compliance to therapy to achieve optimal wellness and management in her asthma condition. Also, because it could a possibility that Tina is becoming tolerant or unresponsive to her albuterol treatment and she might need additional medication, treatments, diagnostics, or intervention to manage better her asthma. Additionally, an allergy testing will be beneficial for pt to identify her asthma and allergens triggers that exacerbate her symptoms.
Pt is diabetic type II and she is noncompliance with diabetes regimen. Pt will be in steroids, which increase her blood sugar level. Proper management of blood sugar is important while pt is on steroids to prevent hyperglycemia, peripheral neuropathy and kidney disease. | Click or tap here to enter text. | |
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References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. |
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| Silkoff, P. E., Sarno, M., Ssenyange, S., Balasubramanyam, V., Awabdy, B., & Leard, R. (2020). Concordance for changes in allergic asthma domain variables after short-term corticosteroid therapy. BMC Pulmonary Medicine, 20(1), NA. Retrieved from https://link.gale.com/apps/doc/A627452226/AONE?u=fjp_jvpl&sid=AONE&xid=3d854118 Alem, K., Gebeyehu, S., & Arega, Y. (2020). Risk Factors and Treatment Types for Asthma Severity Among Adult Patients. Journal of Asthma and Allergy, 167+. Retrieved from https://link.gale.com/apps/doc/A626673913/AONE?u=fjp_jvpl&sid=AONE&xid=fb8b9b1d Spear, L. (2019, November). Nocturnal Asthma: How Sleep Can Affect Asthma Symptoms: Studies show that some asthma patients suffer from worsening symptoms at night, a condition called nocturnal asthma, which can worsen both quality of sleep and quality of life. RT for Decision Makers in Respiratory Care, 32(8), 24+. Retrieved from https://link.gale.com/apps/doc/A625156186/AONE?u=fjp_jvpl&sid=AONE&xid=9edbadcc | |||
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