NR 509 Week 4 Sample Paper

Focused SOAP Note: Acute Asthma Exacerbation in a 34-Year-Old Adult Presenting to Urgent Care

[Author Name]

College of Nursing, Chamberlain University

NR 509 Advanced Physical Assessment

Week 4 Assignment

[Faculty Name]

August 11, 2026

Composite case written as a model document. No real patient, clinic or clinician is described.

What this page is doingThe title names the document type, the diagnosis and the setting, so a reader knows the scenario before the first paragraph. Course and week lines carry the classroom's own vocabulary rather than a fabricated assignment name, which keeps the page honest when the week's deliverable is not published. The closing line states that the case is a composite. Graders reward a title that could only belong to this paper; a generic label such as a bare course code loses that credit for nothing.

Subjective

Chief complaint, in the patient's words: 'My chest has been tight for four days and my rescue inhaler wears off after two hours.' The patient is a 34-year-old woman who arrived at a walk-in urgent care clinic at 3:40 p.m. She reports a dry cough that began five days ago, became productive of scant clear sputum on day two, and has woken her on each of the past three nights. Chest tightness and audible wheeze started four days ago and worsen every evening. She rates breathing difficulty at 6 out of 10 at rest and 8 out of 10 after climbing one flight of stairs. Cold outdoor air and time spent near her sister's cat make the tightness worse; sitting upright and using albuterol help for roughly two hours at a time.

History and medications: asthma diagnosed at age nine, with two courses of oral corticosteroids in the past twelve months and one emergency department visit fourteen months ago; no intubation and no intensive care admission. Allergic rhinitis is treated seasonally. Current medications are albuterol HFA 90 mcg, two puffs every four to six hours as needed, and fluticasone propionate 110 mcg, one puff twice daily. She estimates that she takes the controller inhaler two or three days a week, and that she has used the rescue inhaler eight to ten times a day for the last three days. She does not own a valved holding chamber. No known drug allergies. Environmental allergies to cat dander and grass pollen. She has never smoked, works as a dental hygienist, and lives with a partner and one indoor cat.

Pertinent review of systems. Constitutional: denies fever, chills, night sweats and unintended weight change. Respiratory: reports cough, wheeze and chest tightness as described above; denies hemoptysis and pleuritic pain. Cardiovascular: denies exertional chest pressure, palpitations, orthopnea, paroxysmal nocturnal dyspnea and ankle swelling. HEENT: reports nasal congestion and post-nasal drainage for one week; denies sore throat, ear pain and facial pressure. Gastrointestinal: denies heartburn and regurgitation. Extremities: denies calf pain, unilateral swelling, recent immobility, long-distance travel and estrogen-containing contraceptive use. She reports no personal or family history of venous thromboembolism. Influenza vaccine was received two months ago.

What this page is doingSubjective data stays subjective. The complaint appears in quotation marks in the patient's own words, then a full symptom analysis supplies onset, duration, severity, aggravating factors and relieving factors as reported. Medication names, doses and honest adherence figures sit here rather than in the plan, because the eight to ten rescue doses a day are history, not a finding. The pertinent negatives are not decoration: each one belongs to a differential that appears two sheets later, so the review of systems is already doing diagnostic work.

Objective

Vital signs at triage: temperature 37.1 C oral, heart rate 104 beats per minute, respiratory rate 24 breaths per minute, blood pressure 128/78 mm Hg, oxygen saturation 92 percent on room air, weight 68 kg, body mass index 24.1. Peak expiratory flow measured before treatment was 260 L/min against a documented personal best of 400 L/min, which is 65 percent of personal best. General appearance: alert and oriented, sitting upright and leaning slightly forward, speaking in short phrases of six to eight words, mildly anxious, no accessory muscle use at rest, no tripod positioning, no cyanosis, no diaphoresis.

Focused examination. HEENT: nasal turbinates pale and boggy with clear discharge, oropharynx clear without exudate, no sinus tenderness on palpation. Neck: supple, trachea midline, no lymphadenopathy, jugular venous pressure not elevated at 45 degrees. Lungs: symmetric chest expansion, resonant to percussion in all fields, prolonged expiratory phase with an inspiratory to expiratory ratio near 1 to 3, diffuse high-pitched expiratory wheeze in all lobes and loudest at the bases, no crackles, no rhonchi, no pleural rub, no egophony, tactile fremitus symmetric. Cardiovascular: tachycardic at a regular rhythm, S1 and S2 present, no S3, no murmur, no rub, radial pulses 2+ and equal. Extremities: no edema, no calf tenderness, capillary refill under two seconds. Skin: warm and dry, no rash.

Reassessment after treatment. Following three albuterol 2.5 mg nebulizer treatments given with ipratropium 0.5 mg over one hour, the respiratory rate fell to 18, the heart rate fell to 96, oxygen saturation rose to 96 percent on room air, and peak expiratory flow rose to 330 L/min, which is 83 percent of personal best. Expiratory wheeze became scattered rather than diffuse, and the patient completed full sentences without pausing. Inhaler technique was observed directly: she actuated the rescue inhaler at the end of a deep breath and released it without a breath hold. No chest radiograph was obtained, because the history and examination produced no fever, no focal consolidation, no saturation below 92 percent and no first-time wheeze.

What this page is doingEvery objective line answers a question the subjective raised, and nothing appears here that the visit did not produce. The peak flow is written against a documented personal best so the number carries a denominator instead of floating. Negative findings are recorded with the same care as positive ones, since an absent S3 and clear bases are what let heart failure fall off the list. The reassessment paragraph supplies reversibility, the single piece of evidence that turns wheeze into asthma.

Assessment

Primary diagnosis: moderate acute asthma exacerbation in a patient whose persistent asthma is not controlled (ICD-10 J45.901). The subjective and objective data point to the same place. She reports four days of escalating chest tightness, nocturnal awakening on three consecutive nights and rescue inhaler use eight to ten times daily, a pattern that describes uncontrolled disease on its own; the examination then supplies the matching physical evidence in a prolonged expiratory phase, diffuse expiratory wheeze, a respiratory rate of 24, an oxygen saturation of 92 percent and a peak flow at 65 percent of personal best. Severity is graded moderate rather than severe because she remained oriented, spoke in phrases rather than single words, recruited no accessory muscles and responded to bronchodilator therapy inside one hour.

Differential diagnoses and where each one stands after the examination. Acute bronchitis is plausible given five days of cough with clear sputum, but it does not account for a peak flow at 65 percent of personal best that reversed with a bronchodilator. Community-acquired pneumonia is unlikely with no fever, no focal crackles, no dullness to percussion and no egophony. Decompensated heart failure is unlikely with a normal jugular venous pressure, an absent S3, clear bases and no peripheral edema. Pulmonary embolism is unlikely with no pleuritic pain, no unilateral calf findings, no immobility and a low pretest probability. Vocal cord dysfunction stays on the list because it mimics asthma and can coexist with it, though diffuse expiratory wheeze and clear bronchodilator response favor lower airway obstruction. Allergic rhinitis (ICD-10 J30.9) is a supported secondary diagnosis.

What this page is doingThe assessment argues rather than announces. Severity is graded with named criteria that already appear on the objective sheet, so the word moderate is defensible. Each differential is dismissed by pointing to specific data on the page, not by asserting that it is unlikely, and one differential survives because honest reasoning leaves it open. Naming the secondary diagnosis shows that findings outside the chief complaint were read too. This paragraph is where most points are won or lost.

Plan

Pharmacologic plan. The exacerbation is treated with albuterol HFA 90 mcg, four puffs through a valved holding chamber every four hours for twenty-four hours and then every four to six hours as needed, together with prednisone 40 mg by mouth daily for five days without a taper. Controller therapy is stepped up rather than repeated: the daily inhaled corticosteroid dose is increased, and a combined inhaled corticosteroid with formoterol is discussed as an alternative maintenance and reliever regimen, consistent with current national and international asthma guidance. A valved holding chamber is dispensed at the visit. Cetirizine 10 mg nightly is added for the rhinitis component. No antibiotic is prescribed, because neither the history nor the examination supports bacterial infection.

Monitoring, education and follow-up. Inhaler technique was retaught and returned by demonstration with the holding chamber before discharge, and the two errors seen at the visit were corrected. A written asthma action plan was completed around her personal best of 400 L/min, with green, yellow and red zones set at 320 L/min and above, 200 to 319 L/min, and below 200 L/min. Reduction of cat dander and cold air exposure was discussed. Return precautions were given for speech limited to single words, peak flow below 50 percent of personal best, or rescue inhaler need more often than every four hours. Follow-up with the primary care clinician is scheduled in three to five days for symptom and peak flow review, with pulmonology referral if a second course of oral corticosteroids becomes necessary within twelve months.

What this page is doingEach plan line traces upward to something already established. The dose changes answer the exacerbation, the step-up answers the uncontrolled pattern in the history, the holding chamber answers the observed technique error, and the antihistamine answers the boggy turbinates. Stating why no antibiotic was prescribed shows deliberate reasoning rather than an omission. Return precautions and referral criteria are written as thresholds with numbers, which is what turns education from a sentence into a plan a reader can follow.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Centers for Disease Control and Prevention. (2024). Most recent national asthma data. U.S. Department of Health and Human Services. https://www.cdc.gov/asthma/

Global Initiative for Asthma. (2024). Global strategy for asthma management and prevention. https://ginasthma.org/reports/

National Heart, Lung, and Blood Institute. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. U.S. Department of Health and Human Services, National Institutes of Health. https://www.nhlbi.nih.gov

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis.

How this NR 509 Week 4 example is structured

In many sections this week asks for a focused history and physical write-up in SOAP form; your classroom's instructions decide the exact form, so read the week's assignment page and rubric before you use this NR 509 Week 4 example as a shape. The paper moves in the order a clinician reads: subjective first, so the reader meets the complaint in the patient's own words; objective second, so every finding can be checked against what was reported; assessment third, where the two columns are named as one working diagnosis with differentials the data can rule in or out; and plan last, tied line by line to the assessment above it. The patient is a composite built for teaching. Numbers appear wherever an exam produces numbers.

NR 509 Week 4 questions, answered

What does NR 509 Week 4 usually ask for?

In many sections this week asks for a focused history and physical write-up in SOAP form, built on one system rather than a head-to-toe survey. The exact form belongs to your classroom: read the week's assignment page, the rubric and any template posted with it, since the required sections and the documentation style vary by section.

How much detail belongs in a focused SOAP note?

Enough that another clinician could reach the same diagnosis from the page alone. That means a full symptom analysis, medications with doses and adherence, pertinent negatives tied to your differentials, measured vital signs, and system-specific exam findings. Length follows content rather than a target, and no official word count exists for this week unless your classroom publishes one.

Can I submit this SOAP note as my own work?

No. This is an original model document written to show what a finished focused note looks like, not a submitted paper and not a graded one. Use it to see how subjective, objective, assessment and plan hold together, then write your own encounter with your own data. Submitting any part of it verbatim is plagiarism.

Write yours, or have the desk draft it

This paper is an original model document written by our desk, not a submitted student paper and not an official Chamberlain University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.

NR 509 Week 4: sample paper, in real form