SOAP (Issues) plus D/D plus ICD 10 codes

Subjective: - Patient presents today with a three-day history of a worsening cough, accompanied by a runny nose and fatigue. She reports feeling generally unwell and has a mild headache. - Patient has a history of childhood asthma, well-controlled with an inhaler. No previous surgeries. - Current medications include Salbutamol inhaler as needed. No known herbal supplements. - Patient is a non-smoker and drinks alcohol occasionally. She works as a teacher. - No known allergies. Objective: - Temperature: 37.8°C, Pulse: 88 bpm, Blood Pressure: 120/78 mmHg, SpO2: 98% on room air. - Chest auscultation reveals mild wheezing in the left lung. Throat is slightly red. - No laboratory tests performed at this visit. Assessment: - Acute upper respiratory tract infection. Possible exacerbation of asthma. - Differential diagnoses include: Common cold, influenza. - ICD-10 codes: J06.9, J45.90. Plan: - Continue Salbutamol inhaler as needed. Advised to rest and drink plenty of fluids. Consider over-the-counter pain relief for headache. Review symptoms in one week or sooner if symptoms worsen. - Provided education on proper inhaler technique and signs of worsening respiratory symptoms. - No referrals needed at this time.