Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
Name: MG
Date: 2/16/17
SUBJECTIVE
CC:
“cough and shortness of breath”
HPI:
Pt. Encounter Number: 3983549
Age: 52
Sex: Female
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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
Patient MG of 52-year-old, female patient, with a medical history of asthma who has not taken any
treatment for several years due to the absence of symptoms, comes in this occasion for presenting a cough
of three days accompanied by rhinorrhea, sore throat and fever last night. But she says that since last night
he has difficulty breathing, dyspnea, cough of moderate intensity accompanied by wheezing. She has
difficulty sleeping because of coughing and feels tired.
Medications: Protonix 40 mg 1tab daily. GERD
PMH
Allergies: Penicillin produce Urticaria, rash
Medication Intolerances: N/A
Chronic Illnesses/Major traumas: GERD, Asthma
Hospitalizations/Surgeries: N/A
Family History
Maternal grandmother COPD, maternal grandfather HTN, paternal grandmother Asthma, paternal
grandfather no living dead at 84 years old for Stroke. Father and Mother are healthy. Has two healthy
brothers. She has a cousin with medical history of Asthma and Atopic dermatitis. She has three children,
the oldest one suffers from asthma, the other two children are healthy.
Social History
She has a bachelor degree in Business and Administration, works at a bank as a bank loan analyst. She
lives with her husband and children in a house of her own, has a good economic situation. Do not smoke,
do not drink alcohol, not recreational drugs.
ROS
General
Cardiovascular
Denies weight change, fatigue, fever moderate last
Denies chest pain, palpitations, PND, orthopnea,
night, denies chills, night sweats.
edema
Skin
Denies delayed healing, rashes, bruising, bleeding
or skin discolorations, any changes in lesions or
moles
Respiratory
She refers cough productive, wheezing, and
dyspnea, denies hemoptysis, pneumonia hx, TB
Eyes
Denies corrective lenses, blurring, visual changes of
any kind
Gastrointestinal
She complaint frequently heartburn, nauseas,
burning retrosternal, Abdominal pain, Globus
sensation after meals. She denies constipation,
hepatitis, hemorrhoids, black tarry stools
Ears
Denies ear pain, hearing loss, ringing in ears,
discharge
Genitourinary/Gynecological
Denies urgency, frequency burning, change in color
of urine. No vaginal discharge.
G3P3A0.
No oral Contraception, she uses Natural family
planning
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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds. She
has nasal discharge, clear and throat pain
Musculoskeletal
Denies back pain, joint swelling, stiffness or pain,
fracture hx, osteoporosis
Breast
Denies SBE, lumps, bumps or changes
Neurological
Denies Syncope, seizures, transient paralysis,
weakness, paresthesias, black out spells
Psychiatric
Denies depression, anxiety, sleeping difficulties,
suicidal ideation/attempts, previous dx
Heme/Lymph/Endo
Denies bruising, blood transfusion hx, night sweats,
swollen glands, increase thirst, increase hunger,
cold or heat intolerance
OBJECTIVE
Weight 148
BMI 23.9
Temp 98.9
BP 136/76
Height 5’6”
Pulse 110
Resp 30
General Appearance
Healthy appearing adult female in no acute respiratory distress and anxious. Alert and oriented; answers
questions appropriately.
Skin
Skin is white, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is erythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular, labored; lungs expiratory wheezes in both lung more intense in
bilateral bases to auscultation.
Gastrointestinal
BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveal coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar and vaginal examination done.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
CBC: WBC 11000 Neut: 68
Lymp:36 Mono: 7.7 Eos: 8
Chest x-ray: shows bilaterally increased air volume, low diaphragms, wide diaphragmatic angles, cardiac
silhouette normal. No signs of condensation pulmonary, no pneumothorax no pleurisies.
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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
Special Tests N/A
Diagnosis
1.
2.
3.
4.
Asthma: Asthma is a chronic inflammation of the airways in response to certain stimuli leading to
an exaggerated bronchial response and hyperproduction of mucus. This disease is characterized
by reversible attacks characterized by cough, wheezing and dyspnea. Asthma attacks are triggered
by many factors including infections, allergens, exercise, and sudden changes in temperatures.
Asthma is the most common chronic respiratory disease prevalent in all age groups. Asthma has a
large genetic component by which we see it frequent in individuals of the same family group. On
physical examination, these patients during the asthma attack are anxious with labored breathing,
coughing and wheezing. At the physical examination, we find hyper resonant lungs and wheezes
on auscultation. Although chest x-ray does not give a definitive diagnosis, it can show signs of
bilaterally increased air volume, low diaphragms, wide diaphragmatic angles. As well as helps to
rule out other diseases that can produce cough and wheezes.
COPD: COPD is an obstructive airway disease associated with abnormal inflammatory
responses. This disease is defined clinically by persistent cough for more than three months for
two consecutive years with periods of acute exacerbations. In COPD, the limitation of airflow is
caused by a combination of small airway disease and parenchymal destruction. The main risk
factor is the environmental factor which is composed of cigarette smoke and environmental dust.
Although this disease is treatable, it has a chronic and often irreversible course. The clinic
presentation is very important the toxic habits, the occupation of the patient and the form of
presentation which the most common complaint of these patients is dyspnea on exertion. At the
physical examination, we can find hyperinflation sings such as anteroposterior diameter increase
of the thorax, increase of the intercostal spaces, hyperresonance to the percussion of the thorax,
decrease of the transmission of respiratory sounds and we can hear wheezes but these are more
significant in the asthma. El diagnostic at the physical examination we can find hyperinflation
sings such as anteroposterior diameter increase of the thorax, increase of the intercostal spaces,
hyperresonance to the percussion of the thorax, decrease of the transmission of respiratory sounds
and we can hear wheezes but these are more significant in the asthma. The diagnosis of COPD is
confirmed by means of spirometry since it is considered the gold standard for the diagnosis of
COPD.
Congestive Heart failure: The typical symptoms of heart failure are dyspnea and fatigue. Dyspnea
in heart failure is paroxysmal nocturnal dyspnea and orthopnea as well as shortness of breath
with exercise or at rest. Patients generally present with fatigue and loss of appetite. The symptoms
of jugular venous distention, cardiac enlargement, and a third heart sound (S3), are specific for
heart failure and are not present in our patient. We can also find edemas in inferior members. The
patient with Heart failure has no bronchial obstruction therefore these patients do not present
wheezes in the lungs although there is a picture called cardiac asthma which can manifest with
persistent cough, wheezing or bronchospasm.
Pulmonary Embolism: Pulmonary embolism manifests abruptly of pleuritic chest pain, shortness
of breath, and hypoxia. Symptoms may also manifest with progressive dyspnea. Most of the time
EP occurs as a complication of DVT in lower limbs. Among the symptoms and signs we can find,
tachypnea, tachycardia, cyanosis, rales, S 3 or S 4 gallop and rales in the lungs. In a large
percentage of patients, we can find symptoms of thrombophlebitis.
o
1.
Final Diagnosis
Asthma: This is my final diagnostic due to patient has medical history of Asthma, she has
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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
familiar history of Asthma in several family’s members. The HPI show typical symptoms
of asthma such as SOB, cough and wheezes and the physical exam show expiratory
wheezes in both lungs.
2. Respiratory infection; For cough, sore throat, fever and nose discharge maybe viral
etiology.
3. GERD: Medical antecedents
▪
PLAN including Education
o Plan:
▪
Medication
Albuterol MDI: 90 g/puff, 200 puffs/canisters 2 puffs every 4-6 hours, as needed for
symptoms.
Theophylline 300 mg extended release twice a day for 7 days
Pantoprazole 40 mg 1tab daily by mouth.
▪
Education
a-
bcd-
▪
Non-medication treatments
a-
b▪
Dust mite allergens: Wash bedding weekly in hot water and dry it in a hot dryer.
Encase pillows and mattresses in airtight covers. Remove carpets, especially
from your bedroom.
Avoid use of fabric-covered furniture, especially for sleeping.
Animal fur allergens: Avoid keeping house pets, or at least don’t allow them in
sleeping areas
Smoke allergens: Avoid all of the following: Smoking, contact with tobacco
smoke, smoke from wood-burning stoves or fireplaces
If cold air causes symptoms, wear a scarf over your mouth and nose if you must
go outside during the winter. Avoid vigorous exercise if this causes asthma
symptoms
Diet for GERD avoid spice food, fat foot an avoid eat before go to sleep. Also
avoid any foot that you have found a food that causes an allergic reaction
Follow up
Next appointment for next day to evaluate if patient is stable.
o
References:
Butaro, T. M., Trybulsky, J., Bailey, P.P., & Sadberg-Cook, J. (2013). Primary Care A
Collaborative practice. (4th Ed.). [Vital Source digital version]. Retrieved from
https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/cfi/0!/4/2/2@0:55.7
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Running Head: SOAP NOTE PATIENT CASE 3983549, WEEK 3
Cash, J. C & Cheryl, A. G. (2014). Family practice Guidelines. Retrieved from
https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/cfi/0!/
Goolsby, J. M., & Grubbs, L. (2014). Advanced Assessment: Interpreting Findings and
Formulating Differential Diagnoses, 3rd Edition. [Vital Source digital version]
https://digitalbookshelf.southuniversity.edu/#/books/9780803645011/cfi/0
Quellette, D. R. (2016). Pulmonary Embolism. Retrieved from
http://emedicine.medscape.com/article/300901-overview
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