Asthma SOAP note
Citation: Chaudhari, M. (2023). Asthma SOAP note. Pharmacy infoline. https://doi.org/10.5281/zenodo.10815988
SOAP Notes for 1. Hypertension 2. Angina Pectoris 3. Myocardial Infarction 4. Hyperlipidaemia 5. Rheumatoid arthritis 6. Asthma 7. COPD 8. Diabetes 9. Epilepsy 10. Stroke 11. Depression 12. Tuberculosis 13. Anaemia 14. Viral infection 15. Dermatological conditions
Asthma SOAP note
S – Subjective
The patient is a 28 year female presents to the emergency department because of acute worsening of her asthma symptoms. She reports a history of asthma since childhood but mentions that her symptoms have been well-controlled for the past year. She now complains of not only severe shortness of breath, coughing, wheezing, but also chest tightness that began yesterday evening and have progressively worsened. Although patient denies any recent illnesses, exposure to known allergens, or changes in medication use.
O – Objective:
On examination, the patient appears comparatively distressed and is using accessory muscles for breathing. She has not only audible wheezing but also decreased breath sounds bilaterally. Her initial oxygen saturation on room air is 88%, which improves to 94% during supplemental oxygen via a nasal cannula. Peak flow measurements are significantly decreased compared to her baseline. Vital signs indicate tachycardia and tachypnea.
A – Assessment:
The patient is experiencing a severe asthma exacerbation characterized by acute worsening of symptoms, including not only severe shortness of breath, wheezing, but also decreased oxygen saturation. Her physical examination findings and decreased peak flow measurements confirm the severity of the exacerbation.
P – Plan:
- Immediate Treatment: The patient will receive immediate treatment to relieve her acute symptoms. This includes multiple doses of inhaled short-acting beta-agonists (SABA) and systemic corticosteroids to reduce airway inflammation and bronchoconstriction.
- Oxygen Therapy: Oxygen supplementation will be provided to maintain oxygen saturation above 90%.
- Monitoring: Continuous monitoring of the patient’s vital signs, oxygen saturation, and response to treatment will be carried out. Serial peak flow measurements will be performed to assess improvement.
- Nebulized Medication: If the patient’s response to initial treatment is inadequate, she will receive nebulized SABA for more sustained bronchodilation.
- Chest X-ray: In some cases, a chest X-ray may be ordered to rule out other potential causes of respiratory distress.
- IV Fluids: Intravenous (IV) fluids may be administered to ensure hydration and support in cases of severe exacerbation.
- Consultation: The patient may be evaluated by a pulmonologist for further assessment and recommendations, especially if her response to initial treatment is suboptimal.
- Asthma Action Plan: The patient will receive education on the importance of adhering to her prescribed asthma controller medications and developing an asthma action plan for future exacerbations.
- Disposition: The patient’s disposition will depend on her response to treatment. If her symptoms improve significantly and her oxygen saturation stabilizes, she may be discharged with instructions for home care and follow-up. If she does not respond well, hospital admission may be necessary.
- Follow-up: A follow-up appointment will be scheduled within a week to assess her asthma control, adjust her treatment plan if necessary, and provide further education on asthma management and trigger avoidance.
Here are few more examples of a SOAP note for a patient with asthma:
Example / Case study 1: SOAP note for asthma exacerbation
Subjective:
The patient is a 30 year male presents to the clinic because of difficulty breathing and chest tightness. He reports that he has been experiencing these symptoms for the past week and that they are worse at night and early in the morning. He also reports a history of allergies and occasional wheezing.
Objective:
On examination, the patient has wheezing and decreased breath sounds in his lungs. His oxygen saturation is 95% on room air. Spirometry testing reveals an obstructive pattern consistent with asthma. There are no signs of respiratory distress, and the patient is able to speak in full sentences.
Assessment:
The patient has asthma with symptoms of wheezing, chest tightness, and shortness of breath. His symptoms are worse at night and in the early morning, which is typical of nocturnal asthma. The spirometry test confirms the presence of an obstructive pattern consistent with asthma.
Plan:
The patient will be prescribed an inhaled short-acting beta-agonist (SABA) to relieve his acute symptoms and an inhaled corticosteroid (ICS) to help manage his underlying asthma. He will also be advised to avoid triggers that may worsen his symptoms, such as allergens and smoke. A peak flow meter will be provided to help monitor his asthma control, and a written asthma action plan will be developed with specific instructions for when to adjust medications based on symptoms. Follow-up appointments will be scheduled to assess his response to treatment and adjust the treatment plan as needed.
Example / Case study 2: Asthma exacerbation SOAP note
Subjective:
The patient is a 45-year female presents to the clinic because of a follow-up visit schedule for her asthma. She reports occasional shortness of breath and coughing, which have been relatively stable over the past month. Also mentions that she uses her inhaler as needed, primarily during exercise or when exposed to cold air. Although denies any recent exacerbations or nighttime symptoms.
Objective:
Physical examination reveals clear breath sounds with no wheezing or crackles. The patient’s oxygen saturation is 98% on room air. Peak flow measurements are within her baseline range. The patient demonstrates good inhaler technique.
Assessment:
The patient has well-controlled asthma with infrequent symptoms. There are no signs of an acute exacerbation during this visit.
Plan:
The patient will continue her current asthma maintenance regimen, which includes an inhaled corticosteroid (ICS) as a controller medication and a short-acting beta-agonist (SABA) as a rescue inhaler. She will be reminded to carry her rescue inhaler with her, especially during exercise or exposure to cold air. The patient will return for a follow-up visit in three months for asthma control assessment and medication review.
Example / Case study 3: Pediatric Asthma SOAP Note
Subjective:
The patient is a 12-year-old boy who presents to the pediatric clinic with a history of asthma exacerbation. His mother reports that he has been coughing persistently and experiencing increased shortness of breath, especially at night. She notes that his symptoms have worsened over the past two days. The patient has a history of atopic dermatitis and allergies.
Objective:
On examination, the patient demonstrates audible wheezing and increased work of breathing. His oxygen saturation is 93% on room air. Peak flow measurements are significantly decreased compared to his baseline. The patient appears anxious and uncomfortable.
Assessment:
The patient is experiencing an acute asthma exacerbation with severe symptoms, including nocturnal symptoms and decreased peak flow measurements. This suggests poor asthma control.
Plan:
The patient will receive immediate treatment for his acute exacerbation, including inhaled short-acting beta-agonists (SABA) and systemic corticosteroids. His oxygen saturation will be closely monitored, and if it does not improve with initial treatment, he may require oxygen supplementation. Following stabilization, the patient’s asthma management plan will be reviewed and adjusted to improve control. His mother will be educated on asthma triggers and the importance of adherence to the prescribed controller medications. A follow-up appointment will be scheduled in two weeks to assess his response to treatment and update the asthma action plan.
Frequently Asked Questions (FAQs) on SOAP Notes for Asthma
A SOAP note is a structured method of documenting patient encounters in medical settings. For asthma, it helps healthcare providers organize and communicate patient information using the acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan.
The “Subjective” section includes information provided by the patient or caregiver, such as symptoms, medication use, triggers, and any other relevant information about the patient’s experience with asthma since the last visit.
The “Objective” section contains measurable and observable data gathered during the encounter. This may include physical examination findings (such as lung sounds and respiratory rate), results of lung function tests, peak flow readings, and any relevant laboratory or diagnostic test results.
The “Assessment” section involves the healthcare provider’s professional assessment and interpretation of the patient’s current asthma status. It may include an evaluation of the patient’s asthma control level, the severity of symptoms, and any potential exacerbating factors.
The “Plan” section outlines the recommended course of action based on the assessment. It includes details about medication adjustments, treatment changes, patient education, follow-up appointments, and any other steps to manage and improve the patient’s asthma.
Who typically creates SOAP notes for asthma patients?
SOAP notes are usually created by healthcare professionals involved in the patient’s asthma care, such as physicians, nurse practitioners, physician assistants, and respiratory therapists.
Why are SOAP notes important for asthma management?
SOAP notes provide a structured and standardized way of documenting asthma-related information. They facilitate effective communication among healthcare providers, ensure continuity of care, and serve as a reference for future visits and treatment decisions.
Can SOAP notes be used for both initial visits and follow-up appointments for asthma?
Yes, SOAP notes are suitable for both initial evaluations and follow-up visits. They help track changes in the patient’s condition over time and assist in tailoring treatment plans accordingly.
Are there electronic tools or software for creating SOAP notes for asthma?
Yes, many electronic health record (EHR) systems and medical software offer templates and tools for creating SOAP notes efficiently. These digital solutions help streamline documentation and enhance accuracy.
Do patients have access to their own SOAP notes for asthma?
In some healthcare settings, patients may have access to their medical records, including SOAP notes, through patient portals or upon request. It’s important for patients to discuss access with their healthcare provider or institution.
Citation: Chaudhari, M. (2023). Asthma SOAP note. Pharmacy infoline. https://doi.org/10.5281/zenodo.10815988
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