S.O.A.P.

S: The patient, a 45-year-old male, presents with a chief complaint of persistent cough and shortness of breath for the past two weeks. The cough is dry and occurs mostly at night, while the shortness of breath worsens with exertion. The patient has tried over-the-counter cough syrup with minimal relief. Symptoms have gradually worsened over the past week. He reports similar episodes in the past, usually during the winter months, which were managed with inhalers. The symptoms are affecting his ability to perform daily activities, including his job as a construction worker. He also reports fatigue and occasional wheezing. PMedHx: The patient has a history of asthma diagnosed in childhood, with occasional exacerbations. He underwent appendectomy at age 20. No recent investigations or treatments relevant to the current complaints. Immunizations are up to date. SocHx: The patient is a non-smoker and consumes alcohol socially. He lives with his wife and two children. FHx: Family history of asthma in the mother. O: NAD BP: 120/80 mmHg, HR: 78 bpm, Wt: 85 kg, T: 37°C, O2: 96%, Ht: 180 cm Resp: Chest clear, no decr breath sounds No distension, BS+, soft, non-tender to palpation and percussion. No organomegaly A/P: 1. Asthma exacerbation Assessment: Likely diagnosis is asthma exacerbation Differential diagnosis: COPD, bronchitis Investigations planned: Spirometry, chest X-ray Treatment planned: Prescribe inhaled corticosteroids and bronchodilators Relevant referrals: Referral to pulmonologist for further evaluation 2. Fatigue Assessment: Likely diagnosis is related to asthma exacerbation Differential diagnosis: Anemia, sleep apnea Investigations planned: Complete blood count, sleep study Treatment planned: Address underlying asthma exacerbation Relevant referrals: None at this time