Respiratory SOAP Note Example

Below is a nursing SOAP note for a respiratory examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

• Psychiatric SOAP Note Example
• HEENT SOAP Note Example
• Cardiovascular SOAP Note Example
• Abdominal SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports cough, shortness of breath, and chest pain.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started one week ago.
   • Location: The patient reports experiencing the chest pain in the center of their chest, radiating to their left arm.
   • Duration: The patient mentions that the symptoms have been persistent since their onset.
   • Character: The patient describes the cough as persistent, producing yellowish sputum. They report feeling breathless, particularly with exertion. The chest pain is described as a sharp, squeezing sensation.
   • Aggravating Factors: The patient reports that the symptoms worsen with physical activity and exposure to cold air.
   • Relieving Factors: The patient states that resting and using prescribed inhalers provide temporary relief.
   • Treatment/Interventions Tried: The patient has been using prescribed bronchodilator inhalers and taking over-the-counter cough syrup for symptom relief.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or chronic respiratory illnesses that may be related to the current symptoms. Include details about any previous episodes of asthma, chronic bronchitis, or other respiratory conditions.
4. Allergy History: Inquire about any known allergies to medications, foods, or environmental factors. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including inhalers, oral medications, and over-the-counter remedies for respiratory symptoms.
6. Social History: Explore the patient’s living situation, occupation, hobbies, and any recent exposures to potential respiratory irritants such as smoke, dust, or chemicals. Assess any history of smoking or exposure to secondhand smoke.
7. Family History: Inquire about any family history of respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or other relevant medical conditions. Note any patterns of similar symptoms among immediate family members.
8. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the respiratory system. Inquire about other associated symptoms such as fever, wheezing, nasal congestion, or allergies.

Objective:

1. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 88 bpm, Respiratory rate: 20 breaths per minute, Temperature: 37.2°C.
2. General Appearance: The patient appears in mild distress, breathing with slight difficulty, and using accessory respiratory muscles.
3. Chest Examination: Symmetrical chest expansion, decreased breath sounds and scattered wheezes on auscultation.

Assessment:

1. Medical Diagnosis: Acute exacerbation of asthma.
2. Problem Identification: Patient reports persistent cough, shortness of breath, and chest pain.
3. Relevant Findings and Abnormalities: Decreased breath sounds, wheezes on chest auscultation.
4. Client Education Needs: Patient requires education on asthma management, proper inhaler technique, and triggers to avoid.

Plan:

1. Medical Interventions:
   • Administer prescribed bronchodilator inhalers to relieve acute symptoms.
   • Prescribe a short course of oral corticosteroids to reduce airway inflammation.
   • Monitor oxygen saturation and administer supplemental oxygen if necessary.
2. Patient Education:
   • Educate the patient about asthma triggers and the importance of avoiding them.
   • Demonstrate proper inhaler technique and provide written instructions for future reference.
   • Discuss the use of a peak flow meter to monitor lung function.
3. Referrals or Consultations: Consult with a respiratory therapist for pulmonary function testing and additional education.
4. Safety Measures: Assess the patient’s home environment for potential allergens or irritants and provide recommendations for minimizing exposure.
5. Evaluation:
   • Schedule a follow-up appointment in one week to assess symptom improvement and adjust the treatment plan if needed.
   • Monitor for any signs of worsening respiratory distress or the need for further interventions.

• This example demonstrates a respiratory SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and examination findings related to the respiratory system.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification.
• The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.