Health & Medical Question

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Soap Note:

Subjective Findings:
1. Chief complaint (CC): Patient complains of a persistent cough and wheezing.
2. History of present illness (HPI): The patient states that the symptoms started approximately two weeks ago. The cough is dry and hacking in nature but becomes productive with yellowish sputum in the mornings. The patient reports shortness of breath and wheezing that worsens with physical activity.

Past Medical/Surgical/Social/Family History:
– Past Medical History: The patient has a history of asthma since childhood and has been on albuterol as a rescue inhaler.
– Surgical History: No previous surgeries.
– Social History: The patient is a non-smoker and denies any exposure to smoke or dust. No recent travel history.
– Family History: Mother has a history of asthma.

Medications:
– Allergies: No known allergies.
– Prescription/OTC/Herbal Medications: The patient is currently taking albuterol as needed for asthma symptoms.

Comprehensive Review of Systems (ROS):
– General: Patient denies fever, chills, or weight loss.
– Respiratory: Patient reports cough, wheezing, shortness of breath, and occasional chest tightness.
– Cardiovascular: No chest pain or palpitations.
– Gastrointestinal: No nausea, vomiting, or abdominal pain.
– Musculoskeletal: No joint pain or muscle weakness.
– Neurological: No headache, dizziness, or changes in sensation.
– Skin: No rash, itching, or changes in skin color.
– Psychiatric: Denies anxiety or depression symptoms.

Objective Findings:
1. Physical Examination:
– General: Alert and oriented, no distress.
– Vital Signs: Blood pressure 120/80 mmHg, heart rate 80 bpm, respiratory rate 20 breaths per minute, temperature 98.4°F (36.9°C).
– Chest: Auscultation reveals scattered expiratory wheezes bilaterally.
– Oxygen Saturation: 96% on room air.

2. Diagnostic Testing:
– Chest X-ray: Normal findings.
– Pulmonary Function Tests: Spirometry reveals obstructive pattern consistent with asthma.

3. Screening Tools:
– Allergy Testing: Not performed.

Assessment:
1. Primary Diagnosis: Asthma exacerbation.
2. Differential Diagnoses:
– Chronic obstructive pulmonary disease (COPD)
– Allergic rhinitis

3. ICD-10/CPT Codes:
– Primary Diagnosis: J45.901 (Asthma, uncomplicated)
– Differential Diagnoses:
– COPD – J44.9
– Allergic rhinitis – J30.1

Plan:
1. Diagnostics/Prescriptions/Referrals/Follow-up:
– Order spirometry with bronchodilator response to assess lung function.
– Prescribe albuterol inhaler to be used as needed for asthma symptoms.
– Refer to allergist for further evaluation and consideration of allergy testing.
– Follow-up appointment in 2 weeks to assess treatment response.

2. Patient Education:
– Educate patient on proper inhaler technique for albuterol inhaler.
– Discuss triggers and how to avoid them (e.g., cigarette smoke, allergens).
– Provide information on the importance of adherence to prescribed medications and regular follow-up appointments.

3. Prescription:
– Albuterol inhaler, 2 puffs every 4-6 hours as needed for wheezing and shortness of breath.

Note: If a medication not prescribed, write out a prescription for a medication that might be prescribed for a similar patient. (Answer not provided as it depends on the specific patient scenario.)