SOAP Analysis of Allergy Bronchial Asthma

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Running head: ALLERGY BRONCHIAL ASTHMA

SOAPAnalysis of Allergy Bronchial Asthma

SOAPAnalysis of Allergy Bronchial Asthma

Diagnosisand treatment of various disease conditions are determined by anumber of parameters. At times, the practical assessment of thepatient varies from what is presented in the literature. Thecomparison between the two is important in determining what hashappened in the correct way. This article conducts a SOAP analysis ofa patient with Allery Bronchial asthma against the providedliterature.

Subjectiveanalysis

Thesubjective findings are based on results made as a result of theopinion. Thus, the analysis has collected a number of related datathat include the presence of symptoms such as chest rigidness andshortness of breath. These have been experienced in the last twoweeks as indicated in the literature. In addition, the patient hasexperienced mild dyspnea and coughing through this period. There arehowever some data that is not relevant. Some of these are theproduction of sputum and the treatment of a cold. In addition, thetreatment of appendectomy at the age of 23 and the flu shot inFebruary to cover the past flu season are not appropriate. Norelevant information is revealed from the HEENT analysis. As such,most of it is organized and categorized in the right format with someof the typical symptoms listed first. However, the history thatincludes smoking aspect should have come before the family health dueto its relevance in the diagnosis (Goldberg, 2008).

Objectiveanalysis

Accordingto Pawankaret al. (2009). Objective analysis is made from aspects that are measurable andobservable. In this analysis, the relevant data collected to help inthe prescription include earlier screening such as EKG and the familymedical health, which does not provide any related information. Inaddition, Temperature 98.2 (orally), B/P 138/77, HR 91,Height5.11,Weight 186 pounds. Spo2 95 % on room oxygen are crucial. Thegeneral symptoms that include anxiety and the lack of acute distressare also necessary although they do not produce any relevant results. There are also some unnecessary data. Some of these include theskin, hair and nails analysis. It is not helpful in the diagnosis.They include the presence of chronic gastritis since the age of 29.Therefore, pertinent data and facts have been provided, and theproper documentation used.

AssessmentAnalysis

Assessmentrefers to the evaluation of the recorded symptom and the evaluationof the final opinion. The patient is a 31-year-old man with nochildhood related symptoms. The subjective and objective analysis ismore related to allergy bronchial asthma. It is what relates best tothe purpose of the visit. The results show towards allergy bronchialasthma as opposed to intermittent asthma as is shown in thedifferential diagnosis (Rowe&amp Rowe 1963). It is mainly characterized by episodes of wheezing, chest tightness,coughs and shortness of breath. In this case, intermittent asthmawould show signs of nothing severe as it occurs during the initialstages. It is also an adult onset allergy bronchial asthma since nochildhood related illnesses were referred (Fukuhara, 2011).

PlanAnalysis

Themost appropriate plan that has been recommended for the condition isto perform more diagnostic tests that include Spirometry, peak flowmeter, Chest X-ray and EKG. Non-drug and drug therapies providedinclude Albuterol 2.5 mg/3 mls by nebulization STAT. -Ipratropium0.02% by nebulization STAT. As is appropriate, there is arecommendation for monitoring. It is in the form of follow-up in themedical office after two weeks (Goldberg, 2008).

References

Goldberg,C. (2008). &quotHistoryof Present Illness (HPI)&quot. A Practical Guide toClinical Medicine.University of California San Diego.

Fukuhara,A., et al., (2011). Validation study of asthma screening criteriabased on subjective symptoms and fractional exhaled nitric oxide. AnnAllergy Asthma Immunol.Vol. 107(6):480-6.

Pawankar,R., Holgate, S. T., &amp Rosenwasser, L. J. (2009). AllergyFrontiers: Epigenetics, Allergens and Risk Factors.Tokyo: Springer Japan.

Rowe,A. H., &amp Rowe, A. P. (1963). Bronchialasthma, its diagnosis and treatment.Springfield, Ill: Thomas.