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S.O.A.P. Note TemplateCase ID#: NURS 621_assignment 9.2SubjectiveObjectiveAssessment (diagnosis [primary and differential diagnosis])Plan (treatment, education, and follow up plan)Basic Information22 Year old FemaleSubjective HistoryChief ComplaintShortness of breath and wheezing for 3 days. History of Present IllnessThis is a pleasant 22 year old Caucasian female with a known history of asthma who presents to the clinic with a 3 day history of shortness of breath and increased wheezing. The onset was gradual with minimal wheezing that has progressed over the last 3 days. The patient states she has felt more short of breath while working “on her feet all day at a local coffee shop.” She has used her Albuterol with minimal relief and has used it “more than usual” stating that she has used it a minimum of 5 times per dayfor relief. Her wheezing and shortness of breath are improved with rest but has woken her up from sleep once in the last 3 days. She denies any chest pain, coughing, fever, congestion or sneezing. Her activity level has not increased from her baseline. She endorses working during the day (4 hrs), attending college courses, going out with friends for drinks and going home. She denies any recent increased exertion or exposure to new “allergy triggers.” She lives with 1 roomate and both are non-smokers, no animals in the home and the patient endorses cleaning her home regularly to keep dust at a minimum. She does endorse seasonal allergies and states that the cedar treesnear her home have been blooming. She takes OTC Zyrtec for allergy relief and has taken it daily. She denies any emergency or urgent care visits for her asthma.
Past Medical HistoryThe patients medical history includes mild intermittent asthma (diagnosed at age 10) that is usually well controlled with albuterol only. Seasonal allergies to certain trees, flowers and plants. No surgical history. Last PAP smear 1 year ago and was normal. Nopregnancies, last menstrual period 2 weeks prior. She is up to date on all childhood vaccines and gets her flu vaccine once yearly.