Question

please read the soap note below and write a presentation for it thank you (case presentation)

Joanne Bennett, 29 yr old Caucasian woman

CC: “I have a cough that won’t go away.”

S) HPI: c/o cough for one month. It began suddenly. Noticed that it started around the beginning of spring as weather became warmer. Becomes worse when goes outside, especially at night. Symptoms worse at night and often wakes with coughing. On two occasions coughing fits have caused her to throw up. Denies sputum with the cough. Concerned because during her coughing attacks she sometimes feels that she cannot catch her breath, which is “extremely frightening.” Sometimes sounds wheezy. Taking Robitussin every 4-6 hours, but this is not alleviating her cough. Sleeps w/ 1pillow. Sleeps with windows closed.

PMH: Last Physical Ex was more than 2 years ago. Was told to lose wt. No h/o of asthma or bronchitis. Surgery: none. No hospitalizations.

Meds: birth control pills (Lo-Ovral for the past 2 years). OTC Claritin 10mg for seasonal allergies taken occasionally.

Allergies: NKDA; no food allergies. Seasonal allergies to pollen. Sleep: 8 hours/night when not coughing.   TB skin test neg 6 months ago. Flu shot last winter.

SH: works full time as a receptionist in a corporate office building x 2yrs. Sedentary lifestyle. Her only exercise is walking 3 blocks from BART station to work each day. Non-smoker. Denies drug use. ETOH occasionally. 3 cups of coffee daily. Lives alone in apt; in no current relationship. Has no pets.

                 

FH:           Father: 56, smoker, asthma, COPD, HTN                           PGF: asthma; died age 56 in MVA

                  Mother: 55, smoker, DM type 2, HTN                                 PGM: 78, alive with Alzheimer

                  MGF: died age 68 from CVA                                                    Brother: 25, asthma, obesity

                  MGM: died age 70 from CVA, DM type 2                         

                                   

ROS:   General: Denies recent weight changes, fevers, or chills.

Derm: Denies rash

HEENT: Voice hoarse; no throat pain. No nasal d/c. Denies sinus pain or pressure.

Resp: See HPI

CV: Denies chest pain or SOB with exertion.

Endocrine: Denies excessive hunger, thirst or excessive urination.

MS: Chest muscles tight from coughing. Has mild knee pain sometimes esp with going up stairs.

Psych: Denies depression, thoughts of harm to self or others.

O) Vitals: Temp: 98.5, BP: 124/85, RR: 16, HR: 70, O2 sat: 98%,   Height: 5’2”, wt: 168 lbs BMI: 31

General: obese. Wheezing with inspiration.

Skin: pale. No excessive dryness.

HEENT: Canals clear. TMs visible, translucent, gray, cone of light and landmarks visible. Nasal mucosa pink, clear d/c, septum midline. Oral mucosa pink and moist, no pharyngeal erythema, no exudates, tonsils 2+. No frontal/maxillary sinus tenderness. Neck supple, trachea mid-line. No LAD. Thyroid without enlargement or nodules.

Heart: normal S1, S2, No MRG

Lungs: Diffuse expiratory wheezes throughout. Resonant to percussion, thoracic expansion equal. No increased AP/lateral diameter. No egophany. Tactile fremitus equal.

Extremities: No edema, pulses equal 2+ bilaterally in all 4 extremities.

A) Asthma, triggered by seasonal allergies.

P) #1. Rx: Albuterol HFA MDI 2 puff q 4-6 hours prn wheezing/cough. Flovent MDI 40 mcg 2 puffs BID. Claritin 10mg q am.

                  Dx: none                

                  Pt. Ed: Teach use of peak flow meter; begin learning to self-monitor asthma. Rinse mouth after use of steroid inhaler,

                  F/U: RTC in 2 weeks; bring log of symptoms and use of rescue inhaler.

Answer 1

CASE PRESENTATION

Content:

• Case
• History collection
• Physical examination
• Diagnostic evaluation
• Treatment
• Patient education.

Case:The client 29 yrs old got admitted with complaints of sudden cough for one month,worse during night time,cough begins during spring weather with symptoms of dynea during cough.she is on treatment of robitussin q6h .

History collection:past medical history-she had no history of asthma or bronchitis.no past or present surgical history.family history ofboth father and mother had asthma.she got allergic history of seasonal pollens.

Physical examination:general appearance normal,nose-no discharges,skin-pale ,no dryness,chest auscultaion-diffuse expiratory wheeze present with cough,cvs-normal,extremities-normal,vitals-normal

Diagnostic evaluation:TB skin test negative 6 months ago.

Treatment:

MEDICATION	DOSAGE	ROUTE	FREQUENCY
Albuterol HFA MDI	2 puffs	p/o	q6h/q4h
Flovent MDI	40mcg 2puffs	p/o	b.i.d
T.claritin	10mg	p/o	q am

• Patient education:she should known to manage next attact of allergic asthmatic dynoea and self monitor,
• She can use mask while going out to avoid allergic pollens.
• She should carry medicinal puffs in her pocket every where .
• She should do deep breathing exercises
• She should widely open the mouth and deep inhale puff shots and relax.
• After use of puffs she should throughly rinse mouth.
• She should maintain a log note of episodes of symptom occurance and should come to hospital review after 2 weeks or immediately if symptom worsens.