Focused Soap Note: URI with Asthma Exacerbation

 Focused Soap Note: URI with Asthma Exacerbation

Identifying data:  A is a 17y/o Caucasian female.

Referral: None            Source: Patient and Grandmother      Reliability: Seems reliable

Allergies: NKA  to medications, latex, iodine, x-ray dye, or foods

S

CC: “I feel stopped up and have been feeling like I can’t catch my breath”

HPI: 

3 days ago pt. came home from school with onset of nasal congestion and a dry cough that has progressively worsened and is now accompanied by a sore throat, fever that began yesterday afternoon (Tmax 101.8), yellowish nasal discharge, and a productive cough with tan sputum. Patient’s grandmother kept her home from school yesterday and tried treating her symptoms with OTC Zyrtec and Alka-Seltzer cold medicine which had provided some modest relief of congestion and reduced her fever, but did not improve her cough. Last night she awoke from sleep coughing and was sweating at which time she began to feel short of breath and felt chest tightness; she woke her grandmother who reports she had audible wheezing. Patient was able to gain respiratory relief after using her albuterol inhaler but woke frequently due to coughing. History of childhood asthma which has greatly improved over the years and is now well controlled with a rescue inhaler (albuterol) that she typically uses only a few times per month during or after exercise. Denies night time asthma awakenings other than last night. Denies feeling short of breath or using inhaler since last night. Patient reports that her cough is worse at night and early morning while her sore throat and congestion seem worse during the day.  She reports having slept most of yesterday and still feels tired today. Patient describes a pressure in her face and over her eyes with a headache that seems to come and go for which she had taken cold medicine that contained acetaminophen (Last does 6 hours ago). She denies any change in vision, hearing, ear pain or drainage. Patient does not recall a history of seasonal allergies, but grandmother reports that her pulmonologist had suggested she take Claritin, but has not since she was in middle school. Denies any change in her medications or routine but reports spending the weekend outside at the lake with her church youth group just prior to onset of symptoms. Denies smoking but is exposed to second hand smoke in the home. Denies any difficulty swallowing and maintaining oral intake but does complain of anorexia.  She denies nausea or vomiting, muscle aches, or chest pain.

PMH:

Childhood illnesses: Asthma for which she saw a pediatric pulmonologist until she was 12, but was then instructed to return prn.  Mild scoliosis; Frequent ear infections as a baby. Denies history of dermatitis, GERD, diabetes, heart disease, liver disease, kidney disease or cancer. 

OB/GYN: GOPO. Regular 29-30 day menses cycle. LMP 8/27/12. Pt. denies sexual activity.

Surgical history: Pressure equalization tubes in bilateral ears in 14 and 22 months.

Psychiatric: Denies

Social History: Gen: Lives at her paternal grandmothers house with her father and younger sister. She is a senior at Guntersville High School where she reports making good grades and is hoping to go to University of Alabama Huntsville with two of her best friends next year to work toward becoming an elementary school teacher. She is active in the First Baptist youth group.  Reports regular exercise, but is not involved in team sports. Reports consuming a healthy low fat diet most of the time with occasional splurges. Denies current or past sexual activity, illicit drug use, ETOH use, and tobacco use.

Family History: Allergies (sister), Asthma (sister), hypertension (father), AMI (paternal grandfather), Mental Illness-schizophrenia (mother), Diabetes (paternal grandmother). No family history of cancer, obesity, stroke, kidney disease, vascular disease, liver disease, seizure disorder, or bleeding disorders.

Preventative Care: Immunizations: MMR x 2 doses 2002, 3^rd IVP dose 2005Tdap 2011, HPV x 3 doses 2007,  Meningococcal 2007. Influenza 2011. Dentist: sees regularly, last cleaning and checkup Nov. 2011, got braces removed in 2009, exercises regularly

Current medications: RX: ProAir HFA 2 puffs inhaled Q4-6 hrs prn for shortness of breath and/or wheezing. (Reports using inhaler 3-4/month on average) OTC: Zyrtec 10 mg PO daily for the last two days along with Alka Seltzer cold medicine a couple of times a day for two days.

ROS:

GEN: Reports fever, fatigue, and decreased appetite but denies changes in weight. Denies any skin rashes, lesions, ulcerations, or abnormalities.  HEENT: Reports intermittent tension headaches for the last few days along with decreased sense of smell and significant nasal congestion and drainage as detailed in HPI. Denies change in hearing, ear pain or ringing in the ears. Denies watery or itchy eyes or change in vision.  Reports sore throat as detailed above in HPI. Denies nose bleeds or current problems with tooth pain, bleeding gums, hoarseness, or dry mouth. Respiratory:  Reports cough and SOB and chest tightness as per HPI. Denies hemoptysis, or pain upon inspiration or expiration. CV:  Denies chest pain, high blood pressure, irregular pulse or the feeling of the heart racing or missing beats. Denies any extremity swelling or changes in temperature. GI: Denies nausea, vomiting, hematemesis, abdominal pain, change in bowel habits, or heartburn. GU: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. Regular 29-30 day menses cycle. Denies painful ovulation or cramping. Denies breast tenderness but reports bloating usually just prior to menses. Musculoskeletal: Denies muscle pain or aches, arm or leg weakness, joint swelling or arthritis. Neurologic: Denies syncope, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance. PSYC: Denies depression, anxiety, or changes in mood.

O

Temperature: 99.8 (tympanic), Pulse 76, Respirations 24, BP 94/72 Height: 65in. Weight: 123 lbs  BMI: 20.5; Well groomed teenage female, appropriately dressed in no acute distress but appears obviously ill.

HEENT:. Head: Normocephalic, atraumatic, symmetric, non-tender. Pressure reported upon palpation of frontal maxillary sinuses. Eyes: Sclera white, conjuctiva pink, no icterus, excessive tearing, or exudate ; lids non-remarkable and appropriate for race; no edema or lesions noted;; PERRLA. Visual acuity and extraocular eye movements intact. Ears: Bilateral canals patent and non-tender, but with marked erythema. No edema, lesion, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Nose: Bilateral nares congested with rhinorrhea; boggy, edematous turbinates, yellow drainage noted. Septum midline. Throat: Posterior oropharynx erythematous, but without  tonsillar edema or exudate; uvula midline. Mucous membranes pink, moist, without ulceration.

NECK: supple, non-tender. Mild left anterior cervical lymphadenopathy. No submental, postauricular, or supraclavicular lymphadenopathy noted. No thyroid nodule or thyroidmegaly. Trachea midline.

CHEST: Thorax symmetric, non-tender, with symmetric expansion.  Pt. tachypenic but no use of accessory muscles or evidence of retractions. Breath sounds vesicular with diffuse bilateral expiratory wheezes upon auscultation; no crackles or rhonchi noted.  Lungs resonant upon percussion without evidence of consolidation. Congested cough with small amount of thin yellow-beige sputum.

CV: RRR w/o murmur, rub or gallop. Crisp S1 and S2. Extremities warm, dry and well perfused with 2+ palpable bilateral radial and dorsalis pedis pulses.

ABDOMEN:  flat, soft non-distended and non-tender with no rash, palpable masses or hepatosplenomegaly.  Bowel sounds active. 

INTEGUMENTARY: Skin pink, warm and dry without rash or lesion. Mild facial flushing noted. Elastic with good skin turgor; capillary refill less than three seconds.

A:

1. Acute Upper Respiratory Tract Infection (ICD-9:465.9)  Likely due to combination of viral and allergic causes. Diagnosis supported by sudden onset and clinical presentation of nasal congestion with yellow drainage and boggy turbinates, productive cough with thick tan sputum, fever, and sinus pressure upon exam, lack of evidence of lung consolidation; history of childhood asthma; changing seasons with exposure to environmental allergens and tobacco smoke

2. Acute Asthma Exacerbation (ICD-9: 493.92 with Wheezing (ICD-9: 786.07) and Tachypnea (ICD-9: 786.06) Diagnosis supported by increased respiratory rate and diffuse expiratory wheezes upon auscultation.

Differential Diagnoses: Acute Upper Respiratory Tract Infection- bacterial, Mononucleosis, Bronchitis, Influenza, Pneumonia

Information used to rule out differential diagnosis: Relatively rapid onset with current short duration of symptoms (3 days). No evidence of lung consolidation on exam. Yellowish, not green sputum as commonly seen in bacterial causes, lack of posterior cervical adenopathy as commonly seen in mononucleosis.

Minimal sinus pain and pressure reported at this time without presences of discolored nasal mucus, no fever, no headache. Course of illness > 2 weeks with gradual not acute onset as might be seen with a viral origin. Mild Conjuctival injection noted bilaterally rather than unilaterally, without crusting or eyelids sticking together in the mornings.

P:

Albuterol 5mg NEB x 1 dose now (CPT 94640)

RX:  Promethazine DM 6.25mg-15mg 1 tsp Q4-6 hrs prn for cough;Disp. 180 mL, no

         refills

Medrol Dose Pack;  taper dose as directed by 4mg/day over 6 days beginning with    24mg the first day. Disp. 1 dose pack, No refills.

         ProAir HFA 2 puffs Q 4-6 hrs prn for shortness of breath; Disp 1 inhaler, 3 refills

         Flonase 50mcg/spray; 2 sprays in each nostril daily. Disp: 1, Refills 11.

OTC: Zyrtec 10mg PO daily

          Nasal Saline Spray 1 squirt per nostril BID and prn for nasal congestion

           Acetaminophen 500-1000mg Q 6 hrs prn for fever and headache; Do not exceed

           more than 3 grams/day

Take medications as directed. Continue OTC Zyrtec daily. Complete entire Medrol dose pack and taper as directed in the package. May take Promethazine DM Syrup Q4-6 hr prn for cough; this medication will cause drowsiness and should be with discretion. Take a dose before bedtime to help you rest. Proper administration of Flonase nasal spray provided. Administer to right nostril with left hand and left nostril with right hand while looking at the floor to avoid spraying medication directly onto nasal septum. Continue use of Albuterol inhaler as prescribed for shortness of breath and chest tightness; If rescue medication ineffective and your respiratory status continues to deteriorate report immediately to the urgent care or hospital.

Avoid environmental triggers as much as possible, especially tobacco smoke; Informed grandmother of available smoking cessation resources.  Recommend annual influenza vaccine. May utilize OTC chloraseptic spray and warm salt water gargles TID and prn for relief of sore throat. Continue to maintain adequate hydration with 8 glasses of water per day.

RTC in 3-5 days or PRN for any worsening symptoms, continued fever, green nasal drainage, persistent cough, or SOB.

If  symptoms worsen or persist at time of follow up appointment will consider CBC with differential (CPT 85025) and broad spectrum antibiotic therapy with Augmentin 875mg/125mg PO BID x 10 days. If symptoms persist or at time of resolution of illness will repeat pulmonary function testing and evaluate FEV1 and establish self monitoring with peak expiratory flow rate meter.

J.Entrekin, BSN, RN, UANSON FNP student

References

Epocrates Essentials (2012) [PDA Medical Software]. San Mateo, CA: Epocrates.

Lustig, L.R. & Schindler, J.S. (2012). Chapter 8. Ear, nose, & throat disorders. In S.J. McPhee, M.A. Papadakis, M.W. Rabow (Eds), Current Medical Diagnosis & Treatment 2012. New York: McGraw Hill.