I-Human Case Study Paisley Ward 16 Years Old —
Reason for Encounter: Cough and Shortness of
Breath [Acute Asthma Exacerbation] with SOAP
Note (2025)
,i-Human Case Study: Paisley Ward (16 years old)
Reason for Encounter:
Cough and shortness of breath
Accompanied by mother
Location: Outpatient clinic with exam, lab, and radiology
capabilities
Likely Diagnosis:
Acute Asthma Exacerbation
, Patient History (Subjective Data)
Chief Complaint:
―I’ve been coughing and can’t catch my breath.‖
History of Present Illness (HPI):
Paisley Ward is a 16-year-old female who presents to the clinic
with her mother for evaluation of cough and shortness of breath
that began 2 days ago and has progressively worsened. She
reports wheezing, chest tightness, and difficulty breathing,
especially at night and during physical activity. She used her
albuterol inhaler several times with only partial relief. No fever
or chest pain reported. She rates her shortness of breath as 7/10
in severity.
Reason for Encounter: Cough and Shortness of
Breath [Acute Asthma Exacerbation] with SOAP
Note (2025)
,i-Human Case Study: Paisley Ward (16 years old)
Reason for Encounter:
Cough and shortness of breath
Accompanied by mother
Location: Outpatient clinic with exam, lab, and radiology
capabilities
Likely Diagnosis:
Acute Asthma Exacerbation
, Patient History (Subjective Data)
Chief Complaint:
―I’ve been coughing and can’t catch my breath.‖
History of Present Illness (HPI):
Paisley Ward is a 16-year-old female who presents to the clinic
with her mother for evaluation of cough and shortness of breath
that began 2 days ago and has progressively worsened. She
reports wheezing, chest tightness, and difficulty breathing,
especially at night and during physical activity. She used her
albuterol inhaler several times with only partial relief. No fever
or chest pain reported. She rates her shortness of breath as 7/10
in severity.
