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.
