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MM week 6

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC: 35-year old African American Male, seen for Interview and Physical

exam.

HPI: Patient reports coughing with yellowish sputum production for the past

week. “I am coughing and having difficulty catching my breath”.

Shortness of breath worsens with activity.

PMH: History of Asthma since childhood. No other significant medical history

noted.

ALLERGIES Allergic to penicillin, causing hives.

MEDICATIONS Albuterol Sulfate (HFA) 90mcg, every 6 hours as needed.

Dx- SOB, asthma symptoms.

SH Client reports he lives alone with two cats. He reports he works 40 hours a

week as an office manager with minimal stress. He reports he has good

support from family and work colleagues. He denies any exposure to

secondhand smoke or use of alcohol or illicit drugs. Non-smoker. He

denies any financial barriers and has access to health care.

FH Mother, 66yrs (alive, Asthma)

Father, 70yrs (decreased, COPD/Asthma)

Sister, 33yrs (alive, no known Dx)

Brother, 28yrs (alive, with depression)

HEALTH

PROMOTION &

MAINTENANCE

Client adheres to action plan. Client reports he stays away from his known

respiratory triggers. Client reports he manages his stress with deep

breathing and meditation techniques.

Client follows up annually with PCP. Client actively communicates with

PCP through telemedicine before taking any new

medications/supplements over the counter.

ROS

Constitutional Fatigue reported

Head Denies Headaches, no concerns reported

Eyes No change in vision reported

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

(put N/A in

sections not

completed day of

exam)

Ears, Nose, Mouth, Throat No changes/concerns reported

Neck No change reported

Cardiovascular/Peripheral

Vascular

Client denies chest pain or swelling

Respiratory Client reports SOB ( on exertion)

Breast Denies pain or tenderness

Gastrointestinal Denies abnormal pain, nausea, vomiting or

changes in appetite

Genitourinary Denies burning or pain on urination

Musculoskeletal Denies pain or stiffness

Integumentary Denies any open areas/rashes/burns

Neurological Denies feeling lightheaded or dizzy

Psychiatric (screening tools:

Ex: PHQ-9, MMSE, GAD-

7)

Denies depression or anxiety

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic Penicillin/Rash

Other

O: OBJECTIVE DATA
VITALS: HR: 80bpm RR: 20 BP: 120/80 Temp: 98.6

SpO2%: 98 Ht:5.5 Wt: 147.6 BMI: 24.6

Age: 35 LMP: N/A PAIN:5/10

PHYSICAL

EXAM

(Pertinent data

related to

presenting

problem or

visit type. Put

N/A in sections

not completed

day of exam)

General Appearance Patient appears tired but otherwise well-
nourished and in no acute distress

Head Normocephalic

Eyes PERRLA

ENT, Mouth Tympanic membranes intact, nares

patent, oral mucosa moist without lesions

Neck mild thyroid enlargement without
tenderness

Cardiovascular/Peripheral Vascular Regular rate and rhythm

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Respiratory Bilateral diffuse wheezing on auscultation.

Breast No masses

Gastrointestinal Bowel sounds present in all quadrants

Genitourinary Male

• External Exam No abnormalities noted

• Internal Exam NA

Genitourinary Female

• External Exam N/A

• Internal Exam N/A

Musculoskeletal No deformities

Integumentary No rashes or lesions noted

Neurological Alert and oriented x3

Psychiatric No signs of depression

Endocrine Mild thyroid enlargement noted

Hematologic/Lymphatic No palpable lymphadenopathy

Allergic/Immunologic No acute allergic reactions observed

Other NA

A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES

PRIORITIZE
DIAGNOSIS

1.Acute exacerbation of asthma (Sado, et al.,

2023)

(ICD-10 code:

J45.901).

2.Upper respiratory tract infection (Zhao, et

al., 2022).
ICD-10 code: J06.9

3.Pneumonia (Goyal, et al., 2021) ICD-10 code: J18.9

VISIT CODES CPT BILLING CODES 94640 (Nebulizer treatment) and

99213 (Office visit)

DIAGNOSTICS

POC TESTING None indicated at this time

TESTS REVIEWED None indicated at this time

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

P: PLAN
ACTIONS 1. Diagnosis: Acute exacerbation of asthma.

Diagnostics Order: None indicated at this time.

Therapeutic: Administer nebulized albuterol and ipratropium

bromide combination therapy (Sado, et al., 2023). Consider

systemic corticosteroids (e.g., prednisone) if symptoms do not

improve.

Education: Provide asthma education, including proper inhaler

technique and trigger avoidance. Review asthma action plan.

2. Diagnosis: Upper respiratory tract infection (URTI)

Diagnostics Order: URTI: Consider ordering a rapid strep test or viral

PCR test if warranted by clinical presentation (Zhao, et al., 2022).

Therapeutic: URTI: Supportive care, including rest, hydration, and
symptomatic relief with over-the-counter medications such as analgesics
and antipyretics if indicated

Education: Educate on the importance of rest, hydration, and hand
hygiene to prevent spread of infection. Discuss when to seek medical
attention if symptoms worsen

Consultation/Collaboration: URTI: No consultation or collaboration
indicated at this time

3. Diagnosis: Pneumonia

Diagnostics Order: Order chest X-ray to evaluate for infiltrates and
confirm diagnosis. Consider sputum culture if indicated (Goyal, et al.,

2021)

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

Therapeutic: Initiate antibiotic therapy empirically based on clinical
suspicion and local resistance patterns. Consider hospitalization for
severe cases or those with comorbidities

Education: Provide information on the prescribed antibiotic regimen,
including dosing, duration, and potential side effects. Emphasize the
importance of completing the full course of antibiotics

Consultation/Collaboration: Collaborate with infectious disease
specialist or pulmonologist for further evaluation and management,
especially in cases of severe pneumonia or treatment failure.

PREVENTITIVE

(Used for

comprehensive exams)

Emphasize the importance of hand hygiene and respiratory etiquette to
prevent the spread of respiratory infections to family members and

others.

FOLLOW UP Schedule follow-up appointment in 1-2 weeks for

reassessment of symptoms and asthma control

SOAP Note _______
NU___:_________

Herzing University

Name:_________________________
Typhon Encounter #: _____________________

Comprehensive:____Focused:____

References

Sado, A. I., Afzal, M. S., Kannekanti, L., Pamreddy, H. R., Campillo, J. P., Kandukuri,

V., … & Afzal, M. S. (2023). A Meta-Analysis on Predictors of Mortality Among Patients

Hospitalized for Acute Exacerbation of Asthma. Cureus, 15(2).

Zhao, Y., Dong, B. R., & Hao, Q. (2022). Probiotics for preventing acute upper

respiratory tract infections. Cochrane database of systematic reviews, (8).

Goyal, J. P., Kumar, P., Mukherjee, A., Das, R. R., Bhat, J. I., Ratageri, V., … & Kabra,

S. K. (2021). Risk factors for the development of pneumonia and severe pneumonia in

children. Indian Pediatrics, 58, 1036-1039.

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