Soap Notes Asthma Coursework Example

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Category:
Nursing
Level:
PhD
Type:
GCSE
Pages:
4
Words:
1100
Soap Notes: Asthma Student’s Name Institutional Affiliation Soap Note: Asthma Patients Initials……………… Age…………………… Gender……………………… (S) Subjective data Chief Complaint (CC): Wheezing, Chest tightness, shortness of breath and Chest Pains History of Present Illness (HPI) Mary Paul is a 35yr old Hispanic female who has a past medical history of asthmatic attacks. Currently, she states that the asthma attacks have been occurring after every two hours since yesterday as she was on a team-building trip with her colleagues. The patient has complained of Wheezing, chest pains, shortness of breath and chest tightness. She also states the attack she experienced had no distinguishing features and it was similar to her prior ailments. The patient has complained of having a high fever (98.7) over the past days, extreme tiredness, and she has experienced yellowish-greenish nasal secretions. The last asthmatic attack she suffered was four months ago, and it was not severe. Conversely, Mary Paul has not been hospitalized over the past couple of years due to any Asthma attacks, although she states that she was intubated for asthma ten years ago. Currently, the patient has not been using her Albuterol and Flovent inhalers for the past couple of days. She has denied any coughs, sore throat, trauma, sinusitis symptoms, and cardiovascular attack. Mary Paul states that she has exacerbation when she tries to work out and mostly during fall due to weather changes. However, she explained that the severity of the symptoms decrease after she uses her inhaler and takes a long rest. She checked in today for a medical checkup since the symptoms have increased, making her experience difficulties while breathing. Current medications: Flovent HFA Albuterol MDI Mucinex 1-2 tab PO PRN bronchial secretions. Allergies: No known allergies to Medications or foods. Past Medical History (PMH): Asthma Seasonal Allergies Hypertension. ...
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