*NURSING > CASE STUDY > ADVENCE PH NR565- WEEK 5 ASTHMA CASE STUDY. (All)

ADVENCE PH NR565- WEEK 5 ASTHMA CASE STUDY.

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QUESTION 2 The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by NPs and other healthcare professionals and includes: S: subjective information provided ... by the patient O: objective information obtained by the provider A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information has already been provided to you in the case. P: medical plan. Write a brief SOAP note addressing Haley’s presentation to the clinic and chief complaint. Be sure to include each component: SOAP. A reference is not required for this question. Answer: S: "I can't stop coughing" HPI: Haley, a 10-year old presents to the clinic accompanied by her parents complaining of a persistent cough. She has a history of asthma and reports getting up 3-4 nights to use her albuterol inhaler, in addition to this morning before the office visit. She experiences wheezing 3-4 times a week especially when at the gym or in contact with a cat. Current medications include a SABA. PMI: history of asthma, NKDA Family Hx: Mother- asthma; Father- hypertension, current smoker; no siblings Social Hx: well balanced diet with occasional fast food; gym at school and plays outside daily until symptoms of asthma occur; doing well in school Review of Systems: CONTINUED........ [Show More]

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