NR 509 SOAP Note Week 2 - Respiratory System Assessment

Patient Information

• Initials: T.J
• Age: 28
• Gender: Female

Vitals:

• Height: 170 cm
• Weight: 89 kg
• BP: 140/81
• HR: 89
• RR: 20
• Temp: 98.5°F
• SPO2: 97%
• Pain Rating: Choose an item.

Allergies (and reactions):

• Medication: Penicillin (hives and rash)
• Food: No known allergies
• Environment: Dust (asthma exacerbations, wheezing, chest tightness); Cats (sneezing, itchy eyes, wheezing); No allergy to Latex.

History of Present Illness (HPI)

• Chief Complaint (CC): Shortness of breath
• Onset: 2 days ago, at cousin’s house with cats
• Location: Chest, respiratory tract
• Duration: Every 4 hours, lasts for 5 minutes
• Characteristics: Chest tightness, wheezing, dry cough, waking up at night
• Aggravating Factors: Nighttime, movement, lying flat
• Relieving Factors: Albuterol 90mcg inhaler, briefly
• Treatment: Proventil Albuterol 90mcg inhaler 2-3 puffs for asthma exacerbations, drinks lukewarm water for cough

Current Medications

• Proventil inhaler: 90mcg inhaler, MDI-1-3 puffs as needed, since age 2; doesn’t use inhaler more than 2 times per week. Last exacerbation 3 days ago.

Past Medical History (PMHx)

• Asthma, type 2 diabetes (not currently following treatment regimen)
• Immunizations: UTD, last tetanus within the last year
• PSH: None
• Hospitalizations: Multiple hospitalizations for asthma as a child, last at age 16 for asthma treated with nebulizer treatment.

Social History (Soc Hx)

• Never married; no children, has one brother and one sister; lives with mother and sister in a single-family home to support family after father’s death one year ago.
• Employed at Mid-American Copy and Ship since high school, now a supervisor; understanding boss due to medical reasons.
• Student obtaining Bachelor’s in Accounting.
• Basic health insurance through work but deterred by out-of-pocket costs.
• Strong faith, attends church, volunteers.
• Strong family and social support.
• Stressors related to father’s death, balancing work with school, finances; copes with church support.
• No tobacco use; occasional cannabis use from age 15-21.
• Recreational alcohol use 2-3 times per month.
• Not in an intimate relationship; last sexually active 2 years ago.
• Follows hypoallergenic hygiene, cleans beddings.

Family History (Fam Hx)

• Mother: Hypertension, elevated cholesterol.
• Father: Deceased in a car accident at age 58; had hypertension, high cholesterol, type 2 diabetes.
• Brother: Overweight.
• Sister: Asthma.
• Maternal Grandmother: Died at age 73 of a stroke; hypertension, high cholesterol.
• Maternal Grandfather: Died at age 78 of a stroke; hypertension, high cholesterol.
• Paternal Grandmother: Alive, age 82, hypertension.
• Paternal Grandfather: Died at age 65 of colon cancer; type 2 diabetes.
• Paternal Uncle: Alcoholism.
• Negative for mental illness in the family.

Review of Systems (ROS)

Constitutional:

• ☒Fatigue: Feeling tired due to lack of sleep from waking up at night from SOB.
• ☒Trouble Sleeping: For 2 days.
• ☐Other:

Skin:

• ☒Skin Color: Acanthosis Nigricans.
• ☒Other: Pain, redness, swelling, white pus draining.

HEENT:

• ☒Vision changes: Blurred vision.
• ☒Sore Throat: Dry cough.
• ☒Congestion: Dry non-productive cough.
• ☐Other:

Respiratory:

• ☒Cough: Described as small, dry, nonproductive.
• ☒Dyspnea: x 2 days, every 4 hrs, notes able to take sufficient oxygen with inhalation.
• ☒Wheezing: Related to asthma exacerbations.
• ☐Other:

Neuro:

• ☒Headache.
• ☐Other:

Cardiac and Peripheral Vascular:

• ☒Chest pain: Denies chest pain but reports chest tightness.
• ☒SOB: x 2 days, every 4 hrs.
• ☒Exercise Intolerance: Cough and dyspnea worse with exertion.
• ☐Other:

GI:

• ☒Appetite Change: Excessive hunger.
• ☒Other: Excessive thirst.
• ☐Other:

GU:

• ☒Polyuria: Urinates every hour, or 2-3 times during night.
• ☐Other:

Psych:

• ☒Stress: From work, class, and disease process.
• ☒Anxiety: From disease process and dyspnea.
• ☐Other:

Objective

General:

• Tina Jones, 28-year-old, heavy set, African American woman, slightly frustrated and anxious; seated upright on the examination table. Well-nourished, well-developed, appropriate, clean attire with good hygiene.
• Vitals: 170cm, 89kg, BP 140/80, HR 89, RR 20, temperature 98.5F, and SPO2 is 97%; blood glucose level: 224.
• No decreased level of consciousness. No use of accessory muscles. No acute distress noted. No abnormal HR, RR, or O2 saturation.

Skin:

• Acanthosis Nigricans on cervical collar, dark skin.
• Skin is warm, dry, and intact without rashes or lesions to chest, arms, and back.

Respiratory:

• Few scattered expiratory wheezes auscultated in the posterior left and right lower lobes.
• Thorax is clear of deformities or muscle retraction. Thorax expansion symmetric bilaterally. AP diameter normal, no use of accessory muscles while breathing, no evidence of trauma. Tactile fremitus equal bilaterally with expected, normal fremitus. All areas of lungs resonant with no areas of dullness. Breath sounds present in all lobes. Bronchophony negative.

Assessment

• Moderate-persistent Asthma with exacerbation: J45.41. +cough, +SOB, +chest tightness, +wheezes auscultated posterior lower lobes, -fever, +symptoms worse with exertion. Orthopnea, feeling “like I’m not getting enough air,” exacerbation of symptoms occurring daily, minimal relief from maintenance rescue inhaler.
• Bronchitis: J20.9. +cough, +SOB, -sore throat, -fever, +wheezes auscultated; Fatigue related to troubled sleep caused by worsening symptoms at night, and wheezes present on auscultation, chest tightness.
• Pneumonia: J18.9. +cough, +SOB, -fever, -dullness to percussion, +chest tightness.

Plan

Diagnostics:

• No current need for diagnostic tests. Consider chest x-ray if symptoms persist or worsen.

Medications:

• Beclomethasone dipropionate: 600-1,000mcg per day in 2 divided doses for 3 months.
• Continue Proventil: 90 mcg per puff, every 4 hours as needed.

Referral/Consults:

• Allergist: To identify asthma triggers for better management and symptom control.

Education:

• Teach the importance of using a Peak flow meter and keeping a diary.
• Avoid known allergens such as cats and dust.
• Stress the importance of medication compliance and minimizing exposure to allergens.
• Encourage keeping an asthma exacerbation log.
• Promote a well-balanced diet and adequate hydration.

Follow-Up:

• Return to the clinic for an increase in symptoms, not getting better, or otherwise routine follow-up in 6 months.
• Regular outpatient visits within 1 week, then monthly until a stable phase of asthma plan is achieved.
• Contact office or proceed to the emergency department for any worsening SOB, chest tightness, cough, or allergic reaction signs.

References:

• Allie, E. H., et al. (2018). ED chest radiography for children with asthma exacerbation is infrequently associated with change of management. The American Journal of Emergency Medicine, 36(5), 769-773.
• American College of Allergy, Asthma & Immunology. (2021). When to see an allergist.
• Kaplan, A., et al. (2020). Effective asthma management: Is it time to let the AIR out of SABA? Journal of clinical medicine, 9(4), 921.
• Klingman, K. J., et al. (2016). A Review of Worldwide Patents. Nursing Research, 65(3), 238-248.