SOAP Note for Asthma
Immunization: All the immunizations are fully updated.
Family History: Father died kidney failure at 60 years. Mother died of CHF at 58 years. Her sisters are all healthy with no records of any childhood illnesses.
Social History: she is twelve months month. She has less social history to state
General: coughing dyspnea and exercise intolerance. Denies seizures, swelling extremities and headache.
Hair, skin and nails: Normal with no patches noted on the head. The skin has normal pigmentation, is moist and with no scars. Nails are normal in appearance.
Head: Normal with no injuries.
Neck: Denies any pain and sore throat.
Eyes: No diplopia, or trauma. White discharge noted from the eyes.
Ears: loss of balance and rhinorrhea.
Nose: The nasal mucosa is normal.
Mouth and Throat: No abnormalities
Cardiovascular: Positive for an increased pulse
Respiratory: indicated shortness of breath and increased coughing.
Gastrointestinal: vomiting, nausea, constipation and heartburn.
Musculoskeletal: Gait is normal with effective movement as the patient walks with the parents to and from the working place of the parents.
Peripheral: Sensation was very normal only sensitive to temperatures normal
Neurological: Cranial nerves intact and effective focus changes.
Psychiatric: no anxiety.
Constitutional: BP: 85/60, HR: 75, T: 950F, Weight:9kg’’
General: The patient appears well developed, pale and anxious.
HEENT: PERRLA, TM with no indications of inflammation, no lesions in the oral cavity, no nystagmus.
Cardiovascular: Regular heart rhythm, S1S2 normal.
Chest: Bilateral expiratory wheezes
Lab and Diagnostics:
FEV-FEV1/FVC 60%, FVC 3.0L, 1.8L; Peak flow-76/min; 102/min after albuterol administration.
Chest X-ray; right and left costophrenic angles blunting
CBC: Phenytoin-17, WNL theophylline-6.2
The primary diagnosis for this patient is asthma that is the major cause for the increased symptoms experienced by the patient for the past there days. The patient also indicates that she has been experiencing an increase in the number of asthma attacks in the past few months.
The patient was put on intravenous 0.025% w/v Atrovent to return his breathing back to normal, and an oxygen mask used to improve his air uptake. The drip was continued until the patient could speak well and the breathing had returned. Patient and father were advised to go back to the plan which was working unless it fails again.
Patients guardians were advised on asthma and its care and how they were supposed to ensure that their son stayed taking the prescription. Father agreed to never smoke again close to the family.
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