ADVENCE PH NR565 WEEK 5 ASTHMA CASE STUDY

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