NR603 W2 TD2 SOAP Note

18 August 2024

SOAP Note

Patient: 40-year-old Female, Caucasian

Subjective (S):

  • Chief Complaint (CC): “I think I may have a cold. I’ve been having a hard time breathing on and off lately.”
  • History of Present Illness (HPI): The patient reports experiencing shortness of breath (SOB) primarily at work, which subsides by the time she gets home. She does not experience SOB on weekends, but symptoms return after being back at work for a few hours. A few months ago, she left work due to SOB and was treated at an urgent care facility where she received a breathing treatment and was prescribed antibiotics. The patient denies sputum production, new allergy triggers, or heartburn.
  • Past Medical History (PMHx):
    • Eczema as a child.
    • Seasonal allergies, especially during spring.
    • Saw an allergy specialist 10 years ago and received allergy shots for 5 years with good results.
    • Takes Zyrtec as needed and a multivitamin (MVI).
    • Immunizations: Up to date.
    • Surgeries: Tonsillectomy, Cholecystectomy.
    • Hospitalizations: Childbirth x 3.
  • Allergies:
    • Strawberries: Rash.
    • Erythromycin: Severe GI upset.
  • Family History (FH):
    • Children: Healthy; one daughter currently has a sinus infection.
    • Mother: Deceased at age 80 from congestive heart failure.
    • Father: Deceased at age 82 from lung cancer that metastasized to the brain.
    • Paternal Grandfather: Deceased at age 71 from complications of COPD.
  • Social History (SH):
    • Married, lives with husband and three children.
    • Previously worked in advertising; laid off 18 months ago.
    • Currently works as a Baker’s assistant at an Artisan Bread Bakery, starting work at 4 a.m.
    • Drinks alcohol socially.
    • Smoked 1 pack per week for 3 years in her 20s.
    • Denies illicit drug use.
    • Sleeps 6-7 hours per night.
    • Exercises 4-5 times per week.
  • Review of Systems (ROS):
    • Constitutional: No weight loss, fever, chills, weakness, or fatigue.
    • HEENT:
      • Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.
      • Ears, Nose, Throat: No hearing loss, epistaxis, sneezing, runny nose, or sore throat.
    • Skin: Normal color, warm, dry, and intact. Turgor and capillary refill brisk. No rashes, lesions, or itching.
    • Cardiovascular: No chest pain, pressure, discomfort, palpitations, or edema.
    • Respiratory: Positive for dyspnea. No cough or sputum.
    • Gastrointestinal: No anorexia, vomiting, diarrhea, change in bowel habits, or blood in stool.
    • Genitourinary: Denies dysuria or pain with urination.
    • Neurological: No dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No changes in bowel or bladder control.
    • Musculoskeletal: No muscle, back pain, joint pain, or stiffness.
    • Hematologic: No anemia, bleeding, or bruising.
    • Lymphatics: No enlarged nodes. No history of splenectomy.
    • Psychiatric: No history of depression or anxiety.
    • Endocrine: No reports of sweating, cold or heat intolerance, polyuria, or polydipsia.
    • Allergies: Positive for seasonal allergies. History of childhood eczema. No history of asthma.

Objective (O):

  • Vital Signs:
    • Height: 70"
    • Weight: 140 lbs (63.6 kg)
    • BP: 130/70 mmHg
    • Temperature: 98.0°F
    • Pulse: 75 bpm
    • Respiratory Rate: 18 breaths/min
    • SaO2: 98% on room air
  • General: 40-year-old Caucasian female appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences without appearing breathless.
  • Skin: Skin is warm, dry, and intact. Pale pink in color, no cyanosis or pallor.
  • HEENT:
    • Further details required for completion.

Assessment (A):

Primary Diagnosis:

  • Occupational Asthma Rationale: The patient’s SOB is related to her work environment, specifically in a bakery where she is exposed to flour dust and other potential allergens. Her symptoms subside when she is away from work, which is characteristic of occupational asthma.

Secondary Diagnosis:

  • Allergic Rhinitis Rationale: The patient has a history of seasonal allergies, which may contribute to her respiratory symptoms, especially in an environment with potential allergens like flour.

Differential Diagnoses:

  • Chronic Obstructive Pulmonary Disease (COPD): Considered due to her family history of COPD and lung cancer, though her personal smoking history is minimal.
  • Vocal Cord Dysfunction (VCD): Could mimic asthma-like symptoms, particularly in response to environmental triggers.
  • Gastroesophageal Reflux Disease (GERD): While the patient denies heartburn, GERD can sometimes present with respiratory symptoms without typical gastrointestinal complaints.

Plan (P):

  1. Diagnostic Tests:
    • Pulmonary Function Tests (PFTs): To assess for reversible airway obstruction.
    • Allergy Testing: Consider referral for repeat allergy testing to identify specific workplace triggers.
    • Chest X-ray: To rule out any underlying pulmonary conditions, given her family history.
  2. Medications:
    • Short-Acting Beta Agonist (SABA): Prescribe albuterol inhaler for use as needed for SOB at work.
    • Inhaled Corticosteroid (ICS): Consider initiation depending on PFT results and symptom control.
  3. Patient Education:
    • Educate the patient on occupational asthma and the importance of minimizing exposure to potential triggers at work.
    • Discuss the need for regular monitoring of symptoms and follow-up care.
    • Advise on the potential need for workplace accommodations or changes if symptoms persist.
  4. Follow-Up:
    • Schedule follow-up appointment in 1-2 weeks to review PFT results and assess the effectiveness of the treatment plan.
  5. Referrals:
    • Pulmonologist: Referral for further evaluation and management if PFTs indicate significant obstruction or if symptoms do not improve with initial treatment.