SOAP Note Assignment
Student’s Name
Institutional Affiliation
SOAP Note Assignment
Patient Initials_______
Subjective Data
Chief Complaint
“I have been experiencing shortness of breath, wheezing and coughing once in a day since I was discharged from the hospital 10 weeks ago.”
History of Present Illness
Caucasian female, 65 years of age has a medical history of asthma attacks in the early 20s. Three years ago she was diagnosed with congestive heart failure and doctors advised her to take a sodium restrictive diet along with taking hydrochlorothiazide. Her cardiac symptoms worsened and therefore she was placed on Enalapril, resultantly the symptoms improved last year. 10 weeks ago she had a motor vehicle accident (MVA) and she was admitted to the hospital. After 2 weeks of the accident, she reported post-traumatic seizure and therefore anticonvulsant therapy was initiated. She was administered phenytoin. However, in the last two months, there is an increase in asthma attacks with an average of four times per week. She is also facing difficulty to talk freely and needs breaks to breathe properly. She took albuterol once and came to the hospital for further assessment of her condition.
PHM
She has no previous history of drug allergies. She takes albuterol inhaler as required, theophylline SR capsules 300mg twice daily, phenytoin SR 300mg during bedtime, Enalapril 5mg twice and hydrochlorothiazide 50mg twice. She has never undergone any surgery in the past and currently suffering from asthma, CHF and seizures after the vehicle accident.
Significant Family History
She has a significant family history of hypertension and congestive heart failure. Her father died of kidney failure due to hypertension at the age of 59 and her mother died of CHF.
Social History
She has denied consumption of alcohol and smoking, but she takes 4 cups of coffee ad diet colas daily.
Review of Symptoms
- General: Have pale skin and female anxiousness.
- Integumentary: Denies
- Head: Denies
- ENT: Denies
- Cardio: Denies
- Respiratory: Shortness of breath, wheezing, and coughing
- Gastrointestinal: Denies
- Genitourinary: Denies
- Musculoskeletal: Positive
- Neurological: Denies headache
- Endocrine: Denies
- Hematologic: Denies
- Psychological: Denies
- Objective Data
Objective Data
Vital Signs
- BP 171/94
- HR 122
- RR 31
- T 96.7 F
- 145
- Ht 5’ 3”
Physical Assessment Findings
- HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted.
- Lymph Nodes:
- Carotids: Negative
- Lungs: Negative
- Heart: Regular rate and rhythm normal S1 and S2.
- Abdomen: Soft, non-tender, non-distended and no masses
- Genital/Pulses: Unremarkable
- Rectum: Guaiac negative
- Extremities/Pulses: +1 ankle edema, on right, no bruising, normal pulses.
- Neurologic: A&O X3, cranial nerves intact.
Laboratory and Diagnostic Test Results
- Na – 134
- K – 4.9
- Cl – 100
- BUN – 21
- Cr – 1.2
- Glu – 110
- ALT – 24
- AST – 27
- Total Chol – 190
- CBC – WNL
- Theophylline – 6.2
- Phenytoin – 17
- Chest X-ray – Blunting of the right and left costophrenic angles
- Peak Flow – 75/min; after albuterol – 102/min
- FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%
Assessment
In clinical settings, diagnosis is usually straightforward to determine the potential causes of signs and symptoms. In the current case, the condition of wheezing, shortness of breath and coughing may be associated with a medical history of asthma. However, the patient has been taking an albuterol inhaler to treat asthma. The signs and symptoms improved, but since the motor vehicle accident, the patient is experiencing increased shortness of breath, wheezing and coughing. The patient might be suffering from severe persistent asthma with exacerbation. The ICD-10CC Code for severe persistent exacerbated asthma is J45.51 (American Academy of Allergy Asthma & Immunology, 2019). The patient has a higher respiratory rate of 31 which is ≥25. This high respiratory rate may interfere with language and render the patient unable to complete sentences. The pulse is also recorded to be 122 which indicates the exacerbation of the asthmatic condition. Therefore, there is a potential chance that a patient needs a higher dose of medicines to treat asthma.
Besides that, the patient is also experiencing seizures after an accident and it has been reported to interfere with breathing. Therefore, increased seizures can increase the risk of breathlessness and ultimately enhance the risk of heart disease. The causes of seizure are unidentified and may be due to external causes. The ICD-10CM diagnosis of seizures due to external causes is G40.5 (ICD, 2018). It may be due to hormonal changes, drugs, stress and sleep deprivation. All these factors may be associated with seizures resultantly disrupting the respiratory system causing shortness of breath.
The third potential cause of shortness of breath in the patient may be due to cardiovascular issues. The patient has a medical history of congestive heart failure. One of the studies has reported that congestive heart failure impairs the inspiratory muscle and thus limiting the breathing (Verissimo et al., 2015). The ICD-10CM code for congestive heart failure that is unspecified is 428.0 (ICD, 2018).
Plan
The potential cause of shortness of breath identified from differential diagnosis can be severe asthma with exacerbation. In order to determine whether worsening asthma is the actual cause of shortness of breath, wheezing and cough in the patient it is important to conduct Spirometry, PFTs, and Methacholine Challenge tests. These tests are critical for assessing the worsening condition of Asthma.
Differential diagnosis also revealed that patient may be experiencing some stress or hormonal changes and therefore EEG is the test to identify changes in the electrical patterns of the brain. The sleep test is also important to recognize the lack of sleep in the patient that is causing seizures.
The test to determine the worsening cardiovascular condition includes an electrocardiogram (ECG). It helps in identifying changes in the heart rate and rhythms. Moreover, it also helps in determining the change in heart muscle size (Oseni et al., 2017). After performing all these tests the potential cause of shortness of breath, wheezing and cough in the patient can be accurately determined.
The patient is already on the short-acting beta-agonist and thus long-acting beta-agonist along with an inhaled corticosteroid asthma inhaler. Salmeterol and Beclomethasone inhalers are administered to the patients once in a day. After administering these medications, the patient is expected to show improvements in signs and symptoms. Moreover, for the complication of seizures, the patient is advised to take proper rest and do not think about the motor vehicle accident. The patient is monitored to determine changes in the symptoms. After 1 week of follow up, there is a potential chance that the symptoms improved with medication and the complication of shortness of breath is managed.
Patient education is a critical component of holistic care services. It has been reported that patients who are prescribed long-acting beta 2-agonist may experience the risk of LABA monotherapy (Price et al., 2016). With monotherapy, there is a reduced adherence to the ICS inhaler. Therefore, the patient should be prescribed LABA and ICS in a single inhaler. In this way, the adherence to ICS improves as well as asthma attacks are minimized. Moreover, the patient should be educated regarding the importance of LABA and ICS single inhaler. One of the studies reported that the administration of LABA and ICS in a single inhaler is cost-effective and substantially improves patient outcomes (Tashkin & Strange, 2018). Thus patients should be informed of the potential benefit of this therapeutic regimen to counter worsening asthmatic attacks.
References
American Academy of Allergy Asthma & Immunology. (2019). ICD-10 Coding. AAAA. Retrieved from https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Management/finances-coding/Asthma-Codes-ICD-10.pdf
ICD. (2018). Diseases of the Nervous System. ICD10Data. Retrieved from https://www.icd10data.com/ICD10CM/Codes/G00-G99/G40-G47/G40-/G40.5
ICD. (2018). ICD-10-CM. ICD-10-CM Coding Guide. Retrieved from https://www.unboundmedicine.com/icd/view/ICD-10-CM/955435/all/428_0___Congestive_heart_failure__unspecified
Oseni, A. O., Qureshi, W. T., Almahmoud, M. F., Bertoni, A. G., Bluemke, D. A., Hundley, W. G., … & Soliman, E. Z. (2017). Left ventricular hypertrophy by ECG versus cardiac MRI as a predictor for heart failure. Heart, 103(1), 49-54.
Price, D. B., Colice, G., Israel, E., Roche, N., Postma, D. S., Guilbert, T. W., … & Martin, R. J. (2016). Add-on LABA in a separate inhaler as asthma step-up therapy versus an increased dose of ICS or ICS/LABA combination inhaler. ERJ open research, 2(2), 00106-2015.
Tashkin, D. P., & Strange, C. (2018). Inhaled corticosteroids for chronic obstructive pulmonary disease: what is their role in therapy?. International journal of chronic obstructive pulmonary disease, 13, 2587.
Verissimo, P., Timenetsky, K. T., Casalaspo, T. J. A., Gonçalves, L. H. R., Yang, A. S. Y., & Eid, R. C. (2015). High prevalence of respiratory muscle weakness in hospitalized acute heart failure elderly patients. PloS one, 10(2), e0118218.
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