Women SOAP Note sample
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Geisy M. Vilabrille, MSN, APRN, FNP-C, DNPc
Soap Note # ____
Main Diagnosis _____asthma__________________________________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source: Patient
Allergies: Cold and dust
Current Medications:
- 300mg phenytoin SR capsules; albuterol inhaler PRN 5mg PO BID enalapril; 300mg PO BID theophylline capsules.
PMH: The patient has been asthmatic for ten years now. Patient was also diagnosed with CHF at 4 years ago and appropriate medication prescribed including reducing sodium in her diet. Enalapril will clear CHF symptoms before they become critical.
PSxH: N/A
Social Hx: The patient’s husband is John Goucher 33 and between them is one child aged 2. Patient acknowledges to occasionally drink alcohol and doesn’t abuse it. She is a regular consumer of coffee and tea. The patient says she does regular exercises by jogging and going to the gym. She is not too religious although she occasionally attends church.
Immunizations: is updated
Preventive Care: no history
Family History: The father death at 60 was as a result of cardiac arrest while the mother is 57 and her medical history shows that she suffers from CHF which was diagnosed last year. There no other known related illnesses in other family members.
Sexual Orientation (optional): Straight
Nutrition History: she normally a diet that is Balanced
Subjective Data:
Chief Complaint: “Wheezing and general trouble breathing have grown over the last two days, and I'm beginning to wonder if dust in the compound is responsible.”
ALSO READ: Nursing Discussion Post Help
Symptom analysis/HPI
The patient is an asthmatic woman in her twenties is a regular patient at our clinic. Wheezing and trying to breathe, she's been doing so for the last two days already. As a college student, the patient works at a zoo to earn money for school. She claims to have had two attacks of asthma in the last few months. Her symptoms worsen in chilly weather, particularly early in the morning and late at night, according to the patient.
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. ) not part of your finding during the examination
CONSTITUTIONAL: Coughing and wheezing have been reported by the patient, although she denies any change in weight.
NEUROLOGIC: When asked if she's been having memory loss, the patient says "no." When asked about his or her experiences on LOC, the Pt says he or she had no headaches or head traumas. The patient denies having blurry vision or having trouble seeing. Pt denies that he has any kind of hearing impairment. There is no evidence to support Pt's claims of nosebleeds or difficulties with her sense of smell (Alwarith et al., 2020). A sore throat or raspy voice is not something that Pt claims to have experienced. She claims to not be having any problems swallowing. The patient denies having a painful mouth or bleeding gums.
HEENT: On LOC, the Pt denies having a headache or any other head injury. The patient denies having blurry vision or having trouble seeing. Pt denies that he has any kind of hearing impairment. There is no evidence to support Pt's claims of nosebleeds or difficulties with her sense of smell. A painful throat or raspy voice is not something that Pt claims to have experienced. She claims to not be having any problems swallowing. The patient denies having a painful mouth or bleeding gums.
NECK: flexible, no pains
RESPIRATORY: Pt says she's been gasping and struggling to breathe lately.
CARDIOVASCULAR: Pt She says she suffers shortness of breath but denies having any palpitations or chest problems.
GASTROINTESTINAL: Pt says she does not suffer from either constipation or diarrhea.
GENITOURINARY: Patient denies experiencing either dysuria or polyuria
MUSCULOSKELETAL: Pt says she doesn’t experience back pain, joint swelling, or myalgia.
SKIN: Pt says she hasn’t had any rashes or experiencing itchiness of the skin
PERIPHERAL VASCULAR: does not have peripheral vascular disease
Objective Data:
VITAL SIGNS: BP: 156/90, HR: 115, T: 907F, Weight: 70 kg
GENERAL APPREARANCE: Pt is upright, alert and well groomed
NEUROLOGIC: Pt says she is focused and has never had any incidences of loss of memory
HEENT: PERRLA, TM no inflammation or lesions in the oral cavity.
NECK: no pain
CARDIOVASCULAR: the heart beat is regular, normal.
RESPIRATORY: returned in the affirmative for wheezes
GASTROINTESTINAL: Soft, non-tender, and non-distended abdomens are found in patients.
MUSKULOSKELETAL: Does not have scoliosis
INTEGUMENTARY: Skin is smooth without any rashes
PERIPHERAL VASCULAR: does not have peripheral vascular disease
ASSESSMENT:
Asthma and wheeze are a 26-year-old woman's primary complaints when she arrives at the clinic. After reviewing the patient's medical history, it was discovered that the patient had been diagnosed with asthmatic a few years before. The patient also claims to suffer from wheezing and shortness of breath when exposed to dust and cold temperatures.
Main Diagnosis
Asthma ICD 10: J45
INCLUDE Differential diagnosis
- Pleural Effusion ICD 10: J98.1
- Hypertension with Heart Failure ICD 10: 111.9
- Asthma with acute Exacerbation ICD 10: J45.21
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Pharmacological treatment:
-2adrenoceptor agonist, which can be administered on an as-needed basis to reduce bronchoconstriction and lengthy regulators like corticosteroid, which are taken daily to keep flare ups under control, can ease acute symptoms including coughing, chest tightness, and wheezing.
Non-Pharmacologic treatment: Excessive physical activity, exposure to the elements, and exposure to the cold are all things the patient should avoid. Tobacco use should be avoided; a healthy diet should be introduced; and asthma drugs should be avoided. To help your patient, offer them with the most relevant information. Appropriate medication should be administered to the patient (Krings et al., 2019). There should be no deviation from the doctor's orders for the patient's medicine. If the patient's asthma is under control, the patient should still take the proper medications and avoid environmental triggers; the patient should understand how to evaluate her asthma symptoms.
Follow-ups/Referrals The patient should make a visit to her physician at prescribed date for review or if symptoms persist.
References
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
