Asthma SOAP note
Manisha Chaudhari, HOD, Kokan Gyanpeeth Rahul Dharkar College of Pharmacy and
Research Institute
DOI: 10.5281/zenodo.10815988
S - Subjective
The patient is a 28 year female presents to the emergency department because of acute worsening of
her asthma symptoms. She reports a history of asthma since childhood but mentions that her symptoms
have been well-controlled for the past year. She now complains of not only severe shortness of breath,
coughing, wheezing, but also chest tightness that began yesterday evening and have progressively
worsened. Although patient denies any recent illnesses, exposure to known allergens, or changes in
medication use.
O - Objective:
On examination, the patient appears comparatively distressed and is using accessory muscles
for breathing. She has not only audible wheezing but also decreased breath sounds bilaterally.
Her initial oxygen saturation on room air is 88%, which improves to 94% during supplemental
oxygen via a nasal cannula. Peak flow measurements are significantly decreased compared to
her baseline. Vital signs indicate tachycardia and tachypnea.
A - Assessment:
The patient is experiencing a severe asthma exacerbation characterized by acute worsening of
symptoms, including not only severe shortness of breath, wheezing, but also decreased oxygen
saturation. Her physical examination findings and decreased peak flow measurements confirm
the severity of the exacerbation.
P - Plan:
1. Immediate Treatment: The patient will receive immediate treatment to relieve her
acute symptoms. This includes multiple doses of inhaled short-acting beta-agonists
(SABA) and systemic corticosteroids to reduce airway inflammation and
bronchoconstriction.
2. Oxygen Therapy: Oxygen supplementation will be provided to maintain oxygen
saturation above 90%.
3. Monitoring: Continuous monitoring of the patient's vital signs, oxygen saturation, and
response to treatment will be carried out. Serial peak flow measurements will be
performed to assess improvement.
4. Nebulized Medication: If the patient's response to initial treatment is inadequate, she
will receive nebulized SABA for more sustained bronchodilation.
5. Chest X-ray: In some cases, a chest X-ray may be ordered to rule out other potential
causes of respiratory distress.
6. IV Fluids: Intravenous (IV) fluids may be administered to ensure hydration and support
in cases of severe exacerbation.
7. Consultation: The patient may be evaluated by a pulmonologist for further assessment
and recommendations, especially if her response to initial treatment is suboptimal.
8. Asthma Action Plan: The patient will receive education on the importance of adhering
to her prescribed asthma controller medications and developing an asthma action plan
for future exacerbations.
9. Disposition: The patient's disposition will depend on her response to treatment. If her
symptoms improve significantly and her oxygen saturation stabilizes, she may be
discharged with instructions for home care and follow-up. If she does not respond well,
hospital admission may be necessary.
10. Follow-up: A follow-up appointment will be scheduled within a week to assess her
asthma control, adjust her treatment plan if necessary, and provide further education on
asthma management and trigger avoidance.
Also available at: pharmacyinfoline.com/soap-notes-asthma
