SOAP Note Presentation Responses – Management Considerations for Asthma and Sleep Disorders
Responding to Eunice
Hello,
Great work with your presentation. CC’s case has been covered well. Notably, a couple more things could be considered in management and diagnosis. Gastritis reflux disease (GERD) may be contributing to CC’s nocturnal cough because of his obesity, GERD, and asthma history. GERD is known to trigger asthma attacks, which may worsen his symptoms (Chen et al., 2020). Treating GERD with diet and a proton pump inhibitor may help. Also, CC’s history of dust and pollen allergies and physical exam findings of rhinorrhea and nasal congestion make allergic rhinitis a possibility of his symptoms. Using intranasal corticosteroids or antihistamines to treat his allergic rhinitis may help him sleep better at night and have better overall asthma control.
Further, the frequency of treatment needs to be monitored. According to the guidelines, using a rescue inhaler more than twice a week is a sign of poor asthma control (Papi et al., 2022). There may be a need to start a daily controller medication like a leukotriene receptor antagonist (LTRA) or inhaled corticosteroid (ICS). Also, since CC uses albuterol before intense physical activity like basketball, a pre-exercise inhaler use approach may be considered to prevent exercise-induced bronchoconstriction.
Lastly, spirometry can be a starting point for his lung function assessment, confirm asthma diagnosis and severity, and guide further management (Louis et al., 2022). Monitoring CC’s asthma control and early warning signs of exacerbation can be done by regularly checking his peak flow. For CC’s continued care, an asthma action plan tailored to his triggers and symptoms would be helpful.
References
Chen, C., Zhang, W., Zheng, X., Jiang, C., & Zhang, W. (2024). Analysis of the potential molecular mechanisms of asthma and gastroesophageal reflux disease. Journal of Asthma, 1-13. https://doi.org/10.1080/02770903.2024.2334361
Louis, R., Satia, I., Ojanguren, I., Schleich, F., Bonini, M., Tonia, T., & Usmani, O. S. (2022). European Respiratory Society guidelines for the diagnosis of asthma in adults. European Respiratory Journal, 60(3). https://doi.org/10.1183/13993003.01585-2021
Papi, A., Chipps, B. E., Beasley, R., Panettieri Jr, R. A., Israel, E., Cooper, M., & Albers, F. C. (2022). Albuterol–budesonide fixed-dose combination rescue inhaler for asthma. New England Journal of Medicine, 386(22), 2071-2083. https://doi.org/10.1056/nejmoa2203163
Responding to Hamed Ahmad
Hello,
This is a great case presentation. OSA is a solid diagnosis given the patient’s symptoms of snoring, sleep disruptions, nocturnal awakenings, and occasional choking or gasping for air. People with a BMI in the overweight or obese range, like this patient, often have OSA. His recent weight gain and the positional pattern of his snoring, which is worse when he lies on his back, support this diagnosis. However, we also need to evaluate the differential diagnosis and other possible contributing factors. The patient’s leg movements during sleep justify including restless leg syndrome (RLS) in the differential. As part of your workup, iron studies and vitamin D levels are important since RLS is iron deficiency-related (Anguelova et al., 2020). Since the patient is startled during sleep but does not fully wake up, and his wife has seen him moving his legs, we may also want to consider periodic limb movement disorder (PLMD).
Even though pantoprazole is controlling his GERD well, it may still be a contributor to his sleep problems, especially the feeling of gasping or choking. A comprehensive history and potentially esophageal pH monitoring to evaluate the effect of GERD on his sleep would be helpful. Before the sleep study, the Epworth Sleepiness Scale or other validated questionnaires could be used to measure his daytime sleepiness and support the clinical suspicion of OSA even if polysomnography is the gold standard for OSA diagnosis (Walker et al., 2020).
Finally, since lifestyle changes have been shown to help OSA symptoms, we must follow through. These are dieting, exercising, and weight loss (Gambino et al., 2022). It is essential to remind patients that positional therapy is non-invasive and they can start it right away. It is good and will help guide ongoing management in having a follow-up plan to review the sleep study results and talk to the sleep specialist about therapy options.
References
Anguelova, G. V., Vlak, M. H., Kurvers, A. G., & Rijsman, R. M. (2020). Pharmacologic and nonpharmacologic treatment of restless legs syndrome. Sleep medicine clinics, 15(2), 277-288. https://doi.org/10.1016/j.jsmc.2020.02.013
Gambino, F., Zammuto, M. M., Virzì, A., Conti, G., & Bonsignore, M. R. (2022). Treatment options in obstructive sleep apnea. Internal and Emergency Medicine, 17(4), 971-978. https://doi.org/10.1007/s11739-022-02983-1
Walker, N. A., Sunderram, J., Zhang, P., Lu, S. E., & Scharf, M. T. (2020). Clinical utility of the Epworth sleepiness scale. Sleep and Breathing, 24, 1759-1765. https://doi.org/10.1007/s11325-020-02015-2
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Question 
PLEASE RESPOND on at least two peer’s presentations, offering specific insights, pointing out missed information, suggesting alternate diagnoses or management, etc. Use scholarly citations to support your responses.
Management Considerations for Asthma and Sleep Disorders
PLEASE MAKE SURE THAT THE RESPOND WILL BE BASED FROM THEIR PRESENTATION. Please follow the instructions. Please make it a positive feedback if possible.
Length: A minimum of 250 words per post, not including references
Citations: At least one high-level scholarly reference in APA per post from within the last 5 years
PEER RESPONSE 1:
My name is EUNICE, and I’m here to share with you a patient I saw at the clinic this week. For HIPAA compliance, the patient’s information is redacted and will be known as CC. His initials are CC, and his date of birth is April 16, 2004. He is a 20-year-old Hispanic male who came to the clinic by himself and is a reliable historian. His chief complaint, in his own words, is: “I am here because I’m having intermittent productive cough that gets worse at night, especially at nighttime.”
CC is a 20-year-old Hispanic male with a medical history of obesity and hyperlipidemia. He reports an intermittent productive cough with clear sputum that started two weeks ago and worsens at night and with strenuous activity. He is allergic to pollen and dust and has had two asthma attacks this year, for which he used a rescue inhaler with relief. He denies fevers and exposure to anyone sick. His past medical history includes GERD, obesity, and childhood asthma diagnosed at age 10. He has no prior surgical history or hospitalizations and is up-to-date with all immunizations, including the flu and COVID-19 vaccines. His medications include an albuterol inhaler (90 micrograms, two puffs every 4 to 6 hours as needed for shortness of breath) and atorvastatin (40 milligrams PO daily).
His family history includes a mother with no significant medical history and a father with obesity. His paternal grandmother died at age 65 due to COVID-19, and his paternal grandfather has ESRD and type 2 diabetes mellitus. His maternal grandmother has osteoarthritis, hypertension, and type 2 diabetes mellitus, and his maternal grandfather has type 2 diabetes mellitus and atrial fibrillation. CC lives in a single-family residence with both biological parents, is a full-time student, and works part-time at Disneyland. He enjoys spending time with friends and cousins, playing basketball, and video games. He denies any history of illicit drug use, alcohol, or smoking. There are no pets or a pool at his residence, and he is not sexually active.
In the review of systems, CC denies fevers, chills, headaches, weight gain, or weight loss. His head is normocephalic with evenly distributed hair. He denies eye discharge, vision changes, ear pain, ear discharge, or hearing loss. He reports nasal congestion but denies epistaxis or impaired sense of smell. He also reports intermittent productive cough, shortness of breath, and occasional wheezing, especially at night and during strenuous activity like playing basketball. He denies nausea, vomiting, diarrhea, abdominal pain, weakness, seizures, tremors, depression, and anxiety.
On physical examination, his vital signs were as follows: temperature 98.6°F, pulse 64, respiration 18, BP 122/84, pain 0/10, and O2 saturation 98% on room air. His height is 5’7″, weight 195 lbs, and BMI 30.5, which is considered obese. He appeared well-groomed and in no acute distress. His head was normocephalic and atraumatic, eyes were normal with no styes bilaterally, and external ears appeared normal with pearly white tympanic membranes and good landmarks. His nasal septum was midline, and bilateral nares were congested with rhinorrhea and edema noted. The oral cavity was intact with no lesions. Cardiovascular examination revealed S1 and S2 heart sounds with a regular rhythm, no gallops, and no murmurs. The gastrointestinal examination showed normal bowel sounds in all four quadrants, and the abdomen was soft and non-tender. The genitourinary examination revealed no flank pain, suprapubic tenderness, or CVA tenderness. His skin was warm and dry to touch with color normal to ethnicity. Musculoskeletal examination showed a full range of motion in all four extremities with no gross deformities. Neurological examination revealed cranial nerves II-XII grossly intact. Psychiatric examination showed normal affect appropriate for his age.
Labs and testing included O2 saturation, chest X-ray to rule out complications or other causes of wheezing, and peak expiratory flow rate to determine the extent of asthma exacerbation. Differential diagnoses included bronchiolitis, which is less likely given the patient’s age and lack of expiratory wheezing, and COPD, which is less likely given the patient’s non-smoking status and intermittent symptoms. The primary diagnosis is asthma exacerbation.
The treatment plan includes albuterol (90 micrograms, two puffs every 4 to 6 hours as needed for shortness of breath). If the patient uses it two to three times a week, he should return for re-evaluation and possible prescription of other medications such as corticosteroids or long-acting beta-agonists. Education and plan of care include the importance of having an albuterol inhaler ready at all times, medication compliance, avoiding allergens and asthma triggers, and encouraging annual influenza vaccination. Follow-up includes returning to the clinic to reassess the patient and treatment plan or if symptoms worsen.
PEER RESPONSE 2
My name is Hamed Ahmad, and I will be presenting a case about a 30-year-old Hispanic male. Thank you for taking the time to watch my presentation. This patient, forced by his wife to get checked up, presented with the chief complaint of snoring and sleep disturbances. He came into the office alone, reporting snoring, sleep disturbances, and leg movements during sleep as observed by his wife over the last six months. They have been married for one year, but the past six months have been problematic for his sleep. He notes that his snoring worsens when he is particularly tired and continues when he is lying on his back but stops when he sleeps on his side. He reports being startled and waking up three to four times per week. His wife has also observed him getting startled during sleep but not fully waking up. He has had occasional episodes of choking or gasping for air, about twice in the last six months. The patient denies significant daytime sleepiness but notes occasional fatigue and difficulty concentrating. He denies headaches or other symptoms but experiences nasal congestion due to seasonal allergies. He also has GERD, which causes aspiration at night but is managed with pantoprazole. Over the past year, he has gained about 15 pounds, increasing from 165 to 180 pounds. He admits to not exercising and has tried nasal strips for his snoring without much benefit. There is no family history of sleep disorders, and he denies any history of hypertension, diabetes, or heart disease. His past medical history includes GERD managed with 20 milligrams of pantoprazole daily as needed and a tonsillectomy at age 12. His family history includes a healthy father, a mother with hypothyroidism, a maternal grandfather with liver disease, a maternal grandmother with diabetes, and a paternal grandmother with CHF and myocardial infarction. He works as a software engineer and has no history of tobacco, alcohol, or drug use. His vaccinations are up to date, including childhood vaccinations. He has no allergies except for seasonal ones and has had no hospitalizations.
On review of systems, he reports occasional fatigue but denies fever, weight loss, or chills. His physical examination was normal except for nasal congestion due to seasonal allergies. His vital signs were normal: blood pressure 124/76, heart rate 77, respiration 18, temperature 98.4°F, and O2 saturation 98% on room air. He is 5’7″ tall and weighs 180 pounds, with a BMI of 28.2. He appeared well-groomed and in no acute distress. His physical examination was otherwise normal, with no nasal congestion, septal deviation, or pharyngeal abnormalities. Cardiovascular and respiratory systems were normal, and neurologically he was intact.
My differential diagnosis includes snoring, obstructive sleep apnea (OSA), and restless leg syndrome. My primary diagnosis is obstructive sleep apnea. The plan is to refer him to a sleep specialist for polysomnography (sleep study). While the Epworth Sleepiness Scale could be used, it is not recommended without a sleep study. There are no specific lab tests for sleep apnea, but we will conduct a CBC, CMP, iron studies, vitamin D, and vitamin B12 tests to rule out other causes, including restless leg syndrome. We also performed a thyroid function test and A1C.
For now, there is no treatment until the sleep study is completed. Potential treatments include CPAP or surgical options, to be decided with the sleep specialist. In the meantime, we discussed weight loss, diet, and exercise with a goal of reducing his weight by 20 pounds, which could significantly improve his quality of life and reduce sleep apnea symptoms. He will continue using nasal strips and over-the-counter antihistamines or nasal corticosteroids for allergies. We will follow up with the sleep study results and manage his care with the sleep specialist.
Thank you very much for taking the time to review my presentation. I look forward to your input. Thank you.