Asthma Soap Note

SOAP Note

This SOAP Note provides a detailed evaluation of Mr. Benjamin Clark, a 32-year-old male, focusing on the severity of his asthma, possible triggers, and his response to the current treatment plan.

Information Presented by: Ronald B. Mills from Eco Harmony Solutions

Date: December 3, 2050

Subjective

Objective

Assessment

Plan

  • Patient reports occasional wheezing

  • States he has a difficulty in breathing after physical activity

  • Denies any significant asthmatic attacks recently

  • Expresses concern about how the current season may affect his asthma

  • Vital signs: BP 120/80 mmHg, Pulse Rate 80/min, Respiratory Rate 16/min, Temperature 98.6 F

  • HEENT: No cyanosis or clubbing noted

  • Chest and Lungs: Diffuse wheezing noted, No crackles

  • Patient is second on the stepwise treatment plan for Asthma

  • Posts symptoms and physical examination suggestive of mild persistent asthma

  • Possibility of seasonal triggers challenges asthma control

  • Continue current inhaler with usage as per the stepwise plan for Asthma

  • Advise patient to avoid known triggers whenever possible

  • Follow-up appointment in 2 weeks

Prepared by: Ronald B. Mills, Eco Harmony Solutions

Note Templates @ Template.Net