QUESTION 2

The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by

NPs and other healthcare professionals and includes:

S: subjective information provided by the patient

O: objective information obtained by the provider

A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information

has already been provided to you in the case.

P: medical plan.

Write a brief SOAP note addressing Haley’s presentation to the clinic and chief complaint. Be sure to

include each component: SOAP. A reference is not required for this question.

Answer:

S:

"I can't stop coughing"

HPI: Haley, a 10-year old presents to the clinic accompanied by her parents complaining of a persistent

cough. She has a history of asthma and reports getting up 3-4 nights to use her albuterol inhaler, in

addition to this morning before the office visit. She experiences wheezing 3-4 times a week especially

when at the gym or in contact with a cat. Current medications include a SABA.

PMI: history of asthma, NKDA

Family Hx: Mother- asthma; Father- hypertension, current smoker; no siblings

Social Hx: well balanced diet with occasional fast food; gym at school and plays outside daily until

symptoms of asthma occur; doing well in school

Review of Systems:

 General: No recent change of weight, no fever, chills, diaphoresis

 Cardiovascular: Denies chest pain, palpations, edema, report dyspnea.

 Respiratory: reports shortness of breath, wheezing, chest tightness, cough, denies hemoptysis

and pleurisy

 HEENT: Denies headache, rhinorrhea, or sinus congestion

 GI: denies constipation, diarrhea, and other stool abnormalities

 GU: denies dysurea

 Musculoskeletal: denies back/neck pain or weakness

 Psychiatric: denies depression, anxiety, or suicidal ideations

O:

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Vitals: T:98.2, RR:24. HR:118, BP108/64, SaO2:92%

Height: 56 inches Weight: 72 pounds BMI: 16.1

General: Alert and oriented to person, place, time, and situation, in slight respiratory

distress.

HEENT: PERRLA, no nasal flaring nasal polyps, no swelling of the lymph nodes.

Neck: no JVD, full ROM

Thorax: there is limited chest expansion with use of accessory muscles

Lungs: wheezing, diffuse wheezes bilaterally on expiration and occasionally on inspiration; presence of

breath sounds, decreased breath sounds bilaterally with tight air movement

Heart: Tachycardia with s1 and s2 regular rate and rhythm.

Neurological: cranial nerves intact

A:

Asthma

P:

Haley and her family need to be educated on asthma, its symptoms, and the use of an inhaler.

The patient and her family also need to demonstrate using the metered dose inhaler and spacers.

Haley and her father need to be educated on compliance with the medication regimen to reduce the risk

of asthma-related exacerbation, hospitalizations, and deaths.

The patient and her family need to be educated on the avoidance of triggering factors like pets.

A written asthma action plan needs to be provided with information on asthma, medication change,

including dose, route, and frequency.

Information needs to be provided on recognizing the worsening of symptoms and seeking medical help,

if needed, to Haley and her family.

Haley's father needs to be educated on smoking cessation. Haley is a minor living with her parents, and

education is needed on the triggering effects second hand smoke has on asthma.

QUESTION 3

Based on table 62.9 in your book and the infographic in the course on “The Things to Remember

When Treating Asthma”, how would you classify Haley’s asthma?

Answer:

Haley has moderate persistent asthma.

Haley's asthma can be classified as intermittent asthma related to the use of a SABA PRN for relief of her

asthma symptoms.

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