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Case Information: CC: "My asthma is acting up and I have missed too much school." HPI: BK is a 19-year-old female who presents to the student health clinic complaining of increased SOB, wheezing, poor exercise tolerance, and a head cold for 4 days. She has started taking acetaminophen/aspirin/caffeine (Excedrin Migraine®) recently for headaches. PMH:Moderate persistent asthma for 12 years Perennial allergic rhinitis FH: Both parents living; mother 52 years old with HTN; father 58 years old with COPD (1 pack per day habit); one sibling age 23 in good health SH: no alcohol or tobacco use. Patient is a college sophomore history major and lives in a dormitory with her non-smoking roommate. Her boyfriend has a cat in his apartment. Medications:Albuterol (Proventil®) HFA 2 puffs every 6 hours PRN Fluticasone (Flovent®) HFA 44mcg one puff BID Acetaminophen/aspirin/caffeine (Excedrin Migraine®) 1 tablet PRN headaches Ortho Novum 7/7/7 1 po QD Allergies:Aspirin (wheezing) Cats (wheezing) ROS: Unremarkable except for nasal stuffiness. Patient also reports that she wakes up at least twice a week with SOB and wheezing, and occasionally feels chest tightness in the morning. Physical Exam:GEN: Caucasian female in apparent distress with audible wheezing, suprasternal muscle retractions noted.VS: BP 118/78, HR 95, RR 28, T 98.6, wt 125lb, ht 5’6”CHEST: diffuse wheezes bilaterally on exhalation and occasionally on inspirationCV: regular rhythm; NMRG Labs (non-fasting): Na 137 HCO3 26 BS 104 Plt 220 K 4.4 BUN 18 Hgb 14 WBC 5.0 Cl 102 SCr 0.7 Hct 40
Peak Flow: 200 L/min (baseline 340 L/min)Important considerations for creating a SOAP note: 1.What two or three major problems can you identify with this patient? 2.What subjective/objective information in the case supports each of those problems?