NUR 7070: Advanced Practice Nursing III Practicum (802) Soap Note

Patient: Z.M.

Age: 13 years old

Sex: Male

DOB: 19/6/2012

Subjective

Chief Complaint: “I am having trouble with my asthma.”

History of Present Illness: Z.M. is a 13-year-old African American patient presenting to the clinic with complaints about his asthma. The patient is accompanied by his father and the information provided by the two appears reliable. Z.M. was diagnosed with asthma when he was 8 years old which he has successfully managed using an Albuterol inhaler. His father reports that he was doing well until a few weeks ago when he noticed frequent use of the inhaler. He explains that since the weather started getting cold Z.M. has been having slight trouble breathing. For the past three days, he has had a cough with phlegm which seems to be more pronounced in the morning. He denies to experience common symptoms like shorness of breath, wheezing, and chest tightness. These symptoms are however relieved by a slight rest and the use of 2 puffs of his 90 mcg albuterol inhaler. Z.M. currently denies shortness of breath and reports cough as the predorminant symptom.

WGU C493 Task 1 Leadership Experience Essay proposal change in practice

Allergies: He is allergic to cats, dust, and environmental conditions like cold weather.

Medications: He is currently using Albuterol inhaler 90 mcg, 2 puffs as needed 4 to 6 hourly.

PMH: No PMH

Past surgical history: Asthma that was diagnosed at the age of 8 years.

Immunizations: All immunizations are up to date.

Family History:

Mother: 43 years old with hypertension

Father: 46 years old with asthma

Sister: 18 years old with asthma

Maternal grandfather: 77-year-old with arthritis.

Maternal grandmother: 71-year-old with obesity and hyperlipidemia.

Paternal grandfather: 81-year-old with asthma.

Paternal grandmother: 76-year-old with HTN, diabetes, and COPD.

Family: eczema as a child

Social History: Z.M. is a middle-school-aged child who resides in an urban neighborhood. He enjoys riding to school with the bus every morning and playing with other kids at school. He likes playing basketball and riding bikes at the local park. His father states that he eats a healthy diet, but consumes a lot of fast foods most times of the week due to the busy family lifestyle. His father denies exposure to smoke, tobacco, or alcohol at home because no family member consumes those products.

Nutrition: His diet is made of fast foods most of the week.

Elimination: reports normal bowel movement and control.

Sleep: Z.M. sleeps for 9 hours at night without any problem.

Vision: There are no concerns for vision today.

Hearing: There are no concerns for hearing today.

Development & Behavior: There are no concerns for his development. His father reports some defiant behavior.

Safety: He uses safety gear when riding bikes and playing basketball, and skating.

Review of Systems

General/Constitutional: Reports fatigue and shortness of breath when exercising. Denies weight loss, night sweats, or chills.

HEENT: Denies vision changes, difficulty hearing, runny nose, mouth sores, loose teeth, ear pain, sore throat, and neck pain.

Respiratory: Reports occasional wheezing, cough, and shortness of breath.

Cardiovascular: Denies chest pain, palpitations, or edema in extremities

Integumentary: Denies rash, color changes, or lesions.

Gastrointestinal: Denies anorexia, abdominal pain, nausea, vomiting and diarrhea.

Musculoskeletal: Denies joint pain, swelling, stiffness, fractures, or ROM issues.

Neurological: Denies dizziness, headaches, syncope, sudden loss of consciousness, or seizures.

Mental: Denies sleeping difficulty, behavioral changes, and developmental concerns.

Objective

Physical Examination

Vitals:

Temp: 98.5 F

BP: 108/72

HR: 106

RR: 19

SPO2: 98%

Measurements:

Ht: 68 inches

Wt: 164 pounds

BMI: 24.9 (94%, At risk for overweight)

General: He is in no apparent distress, clean, well-groomed, and is appropriately dressed. Answers questions appropriately for age.

HEENT: Head: normocephalic and symmetric. Face is symmetric. Ears: The external auditory canal and tympanic membranes are clear. No abnormalities found to left and right auricles, non-tender to palpation bilaterally. No abnormalities found with left auditory canal. TMs gray and intact with expected light reflection. No redness or swelling noted. Nose: Nares are patent bilaterally, the septum is midline, and the mucosa is pink with no discharge. Throat: No swelling or palpable masses on neck. Oral Mucosa are pink and moist. Oropharynx is pink and moist. The pharynx is without edema, erythema, or exudates.

Tina Jones HEENT Shadow Health Objective Data

Cardiovascular: S1 S2 heard, no murmurs, rubs, clicks, or gallop.

Respiratory: Lungs are clear to auscultation, no adventitious sounds heard in all fields, and there are no diminished breath sounds. Respiratory rate is normal and percussion reveals normal tympany.

Gastrointestinal: The abdomen is soft, non-tender, non-distended and the bowel sounds are normoactive.

Genitourinary: No bladder distention, loss of bladder control, or bed wetting issues.

Skin: Warm, dry, and intact. No rash, pallor, lesions, or cyanosis noted. Capillary refill on upper and lower extremities is less than 3 seconds.

Musculoskeletal: Full range of motion in all four extremities, grossly normal function, and strength of extremities. No bone, joint, or muscle tenderness or swelling noted.

Neurological: The speech is clear, displays normal posture, stable balance, and symmetrical movements.

 Assessment

Pulmonary function tests: Mild restrictive pattern disease

FVC: 77%

FEV1: 85%

FEV1/FVC: 109%

Differential Diagnoses

Mild Intermittent Asthmas (J45.2)

This form of asthma is characterized by frequent symptoms that occur less than twice a week and nocturnal awakenings less than twice a month (Rothe et al., 2018). The patient may present with short episodes of wheezing, coughing, chest tightness, and shortness of breath, typically triggered by allergens, exercise, or respiratory infections.

Z.M. explains that his asthma symptoms started during the cold season but do not involve symptoms like nocturnal awakening. In addition, it is unlikely that the patient has mild intermittent asthma because of the abnormal PFT results.

Unspecified asthma with (acute) exacerbation (J45.901)

Acute asthma exacerbation involves sudden worsening of asthma symptoms due to the tightening of muscles around the airways, increased inflammation, and mucus production. Individuals usually present with wheezing, chest tightness, and difficulty speaking, and it is mainly triggered by allergens (Al-Shamrani et al., 2019).

Z.M. is unlikely to suffer from this condition because he is calm, has no wheezing, and has no breathing difficulties. In addition, acute exacerbation requires the use of fast-acting bronchodilators to relieve symptoms which Z.M. does not require at this time.

Acute bronchitis, unspecified (J20.9)

Acute bronchitis is an inflammation of the bronchial tubes, the airways that carry air to your lungs, usually caused by viral infections, such as the common cold or flu (Schubert et al., 2023). It manifests with symptoms that include a persistent cough, which may produce mucus that is clear, white, yellow, or green; wheezing; a low-grade fever; chest discomfort, and fatigue.

Z.M. explains that symptoms of chest tightness and cough with phlegm are experienced. However, the lack of key features like fever and sputum that is white, yellow, or green indicates that he is less likely to suffer from acute bronchitis (Schubert et al., 2023). In addition, acute bronchitis resolves in a few weeks and does not require the use of an inhaler like in the patient’s case.

Working Diagnosis

Cough variant asthma (J45.991)

Cough variant asthma is a type of asthma whose predominant symptom is chronic cough. The cough can be productive or dry and it usually lasts for more than 8 weeks (Niimi, 2021). Unlike typical asthma, individuals with cough variant asthma do not usually experience the classic symptoms of wheezing and shortness of breath. The cough is often worse at night, can be triggered by exercise, cold air, or allergens, and is unresponsive to over-the-counter cough medications.

Z.M. is likely suffering from cough variant asthma because his chief complaint is coughing accompanied by phlegm for 3 days. His father states that he has had the symptoms for a while and they started during the cold season. Cough variant asthma usually responds to asthma medications like inhalers as observed in the patient’s case (Niimi, 2021). Pulmonary function tests in cough variant asthma may reveal restrictive patterns as observed in the patient.

Plan

1. Prednisone 20mg BID for 5 days. Prednisone is an oral corticosteroid used to reduce inflammation in the airways. For cough variant asthma, a short course of prednisone can help to quickly decrease airway inflammation and improve symptoms (Ramadan et al., 2019).
2. Singulair 10 mg PO daily. Montelukast is a leukotriene receptor antagonist that helps to reduce inflammation and bronchoconstriction in asthma (Cloutier et al., 2020). The use of this medication can achieve long-term control of asthma and help with allergic components of asthma.
3. Flovent 2 puffs BID (110mcg per inhalation). Flovent is an inhaled corticosteroid that helps to maintain long-term control of asthma by reducing inflammation in the airways (Averell et al., 2022). This medication will help to control coughing and improve lung functioning.
4. Educate the patient on recognizing early signs of asthma exacerbation, proper inhaler technique, and adherence to the prescribed regimen.

References

Averell, C. M., Laliberté, F., Germain, G., Duh, M. S., Lima, R., Mahendran, M., & Slade, D. J. (2022). Symptom control in patients with asthma using inhaled corticosteroids/long-acting β2-agonists (fluticasone furoate/vilanterol or budesonide/formoterol) in the US: A retrospective matched cohort study. Journal of Asthma, 59(9), 1805-1818. https://doi.org/10.1080/02770903.2021.1963767

Al-Shamrani, A., Al-Harbi, A. S., Bagais, K., Alenazi, A., & Alqwaiee, M. (2019). Management of asthma exacerbation in the emergency departments. International Journal of Pediatrics & adolescent medicine, 6(2), 61–67. https://doi.org/10.1016/j.ijpam.2019.02.001

Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., … & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003

Niimi A. (2021). Narrative Review: How long should patients with cough variant asthma or non-asthmatic eosinophilic bronchitis be treated?. Journal of Thoracic Disease, 13(5), 3197–3214. https://doi.org/10.21037/jtd-20-2026

Rothe, T., Spagnolo, P., Bridevaux, P. O., Clarenbach, C., Eich-Wanger, C., Meyer, F., Miedinger, D., Möller, A., Nicod, L. P., Nicolet-Chatelain, G., Sauty, A., Steurer-Stey, C., & Leuppi, J. D. (2018). Diagnosis and management of asthma – The Swiss Guidelines. Respiration; International Review of Thoracic Diseases, 95(5), 364–380. https://doi.org/10.1159/000486797

Schubert, N., Kühlein, T., & Burggraf, L. (2023). The conceptualization of acute bronchitis in general practice – a fuzzy problem with consequences? A qualitative study in primary care. BMC Primary Care, 24(1), 92. https://doi.org/10.1186/s12875-023-02039-z