SUBJECTIVE: The patient returns today in followup for asthma and an abnormal chest CT scan. Over the last two months, she has been doing very well. Her asthma has been in good control. She has had no coughing or wheezing. She has had no hemoptysis. She has had no sinus congestion. She does have some occasional gastroesophageal reflux and uses Prevacid on an as-needed basis. She has only used ProAir once in the last three months.
Past medical history includes asthma, pneumonia, gastroesophageal reflux disease, and status post tonsillectomy.
Medications include ProAir p.r.n., multivitamin, calcium, vitamin D and Prevacid p.r.n.
OBJECTIVE: She is well appearing, in no acute distress. Blood pressure 96/54, pulse 72. Room air oxygen saturation 98%. Head and neck exam were benign. Her lungs are clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm. S1, S2. Extremities: No clubbing, cyanosis, or edema.
We were able to review her most recent chest CT scan and compared it to her prior studies dating back to XXXX. There is a persistent area of linear atelectasis in the lingula. In the right middle lobe, there is a patchy irregular linear density that has progressed. There appears to be some minimal bronchiectasis.
ASSESSMENT AND PLAN: The patient is a pleasant (XX)-year-old woman with a history of mild intermittent asthma. Currently, her asthma is in good control. She had pulmonary function tests from MM/DD/YYYY, which showed only a borderline mild obstructive ventilatory defect.
We think it is reasonable that she uses ProAir on an as-needed basis. If she is more symptomatic, we have asked that she call us. We could consider starting an inhaled corticosteroid. Her chest CT scan does show some atelectasis in the lingula, which has been stable since XXXX.
In the right middle lobe, there was a small area of bronchiectasis. It is more prominent at this point. This may be related to the pneumonia she has had in late October. We would like to check one followup chest CT scan, low-dose, without contrast. If there is persistent atelectasis in this area, we may need to consider bronchoscopy.
Asthma SOAP Note Template Sample #2
SUBJECTIVE: The patient is a (XX)-year-old male we are seeing for the first time. He is here for poor control of his asthma. On questioning, it is probably due to noncompliance because he had some insurance problems. Also, he has a habit of stopping his medications when he feels well. He has a history of lifelong asthma. He has been skin tested and found to have multiple allergies including to trees and mites among others. He does practice good dust mite prevention. He thinks his control may be better ever since he moved into his house. He has been living in the same house for seven years. Prior to that, he lived in a very old house, which exacerbated his asthma. He did have immunotherapy in the late 80s going to the 90s.
His symptoms for asthma include wheezing and chest tightness and coughing. He will have what he describes as bronchitis 4 times a year, characterized by coughing in the morning, productive of green phlegm. He does say he has a problem with postnasal drip. He was given a nasal steroid which he neglected to use. He denies any recent hospital or emergency room visits for his asthma. He is a nonsmoker.
As noted, he has lived in his current house for seven years. There are no animals in the house. There is carpeting in the bedroom, but he does vacuum twice weekly.
Past medical history is significant for panic attacks, deviated septum, and alcohol use.
OBJECTIVE: Today, there is no sinus tenderness. There looks to be a slightly deviated septum. HEENT examination is benign without sinus tenderness. The neck is supple without thyromegaly or lymphadenopathy. Lungs: Entirely clear without rhonchi, rales or wheezing. Cardiovascular: Within normal limits. Abdomen: Soft and benign.
ASSESSMENT AND PLAN: The patient has asthma that is poorly controlled, mainly due to noncompliance. We educated him on the importance of control on medications. He agrees to use his Flovent on a regular basis. His poor control also may be due to chronic postnasal drip, which may be leading to sinusitis and bronchitis. We will put him on a nasal steroid 2 sprays in each nostril twice a day. He understands the point of using this on a frequent basis. The plan is to see how he does on this and see him in 2 to 3 months’ time.
