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Assignment 9.1: Topic-Based SOAP NoteCase ID#:SubjectiveObjectiveAssessment (diagnosis [primary and differential diagnosis])Plan (treatment, education, and follow up plan)Basic Information22-year-old female presents with a history of asthma and three days of increased wheezing and shortness of breath. She works at the local zoo during the summer to save money for the school year.Subjective HistoryPatient comes in with c/o difficulty breathing with SOB and wheezing over the last three days. She does report being diagnosed with asthma at the age of 10 as well as working at the local zoothis summer prior to continuing school again this fall.Chief ComplaintIncreased wheezing and SOB over the past 3 days.History of Present Illness22-year-old patient presents with a history of asthma and three days of increased wheezing and shortness of breath. She works at the local zoo this summer prior to going back to college in the fall. She indicates that she has had two “asthma attacks” in the past three months since she has been home for the summer and working at the zoo. The reports that the symptoms become worse when she is exposed to the cold in the morning when she goes outside for her job. She also reports that it feels as though exposure to the animals at the zoo seem to make it worse as well. She states, “I was doing fine at college all year and barely had any symptoms and rarely used my rescue inhaler but this summer it seems like it has been horrible.” She reports that she has been home for three months for summer break and still has another three weeks working at the zoo before going back to college. Patient also states, “the last two times I had these attacks overthe last three months I just use my rescue inhaler a lot and waited for it to get better but this timeit just doesn’t seem to be doing the trick.” She does report using her rescue inhaler multiple times throughout the day especially when she is working at the zoo. She has been waking up at least once at night with symptoms as well.
Past Medical HistoryAllergies: NKAPast Medical History: AsthmaPast Surgical History: None Patient receives flu vaccine every year and plans to get this fall at college when they start offering it.She is up-to-date on all her child immunizations.Current Medications:Albuterol Inhaler 90 mcg 2 puffs Q4-6 hours PRN NuvaRing 1 Q4 weeks-3 weeks in and 1 week outTylenol 650mg as needed Family HistoryMother-age 55; no medical history to reportFather-age 56; HTN, HLD, asthmaBrother-age 18; asthmaSister-age 13; no medical history to reportMaternal Grandmother-age 78; hx of strokeMaternal Grandfather-age 79; HTN, Parkinson’sPaternal Grandmother-age 72; asthmaPaternal Grandfather-age 75; HTN, CAD, MI w/ CABGPersonal/Social HistoryPatient is currently not married but is in a relationship with her boyfriend of 2 years and is sexually active. She is attending Lincoln Tech and majoring in Medical Assistant. She currently works at the Lehigh Valley Zoo during the summer until she goes back to college in the fall. She