Focused SOAP Note Template And Patient Information Case Study

Discussion during and after OSCE

Patient presents to the clinic with difficulty breathing for 2 weeks.

Patient reports shortness of breath, cough. Denies pain.

Patient denies any recent respiratory infection or illness. Denies changes to medications.

Patient has history of COPD.

Patient states activities worsen symptoms.

Denies exposure to potential irritants or allergens.

No recent travels to areas with higher pollution levels. Focused SOAP Note Template And Patient Information Case Study

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Review of system

Physical exam

Labs/Diagnostic/Imaging

CBC, CMP

Chest x-ray

ABG, etc

Administer O2 at 2L to improve saturation.

Administer nebulizer treatment.

Spirometry with Pulmonologist when patient is stable.

Discuss smoking cessation and provide resources (patient is not ready at the time, information provided).

Differential diagnosis

COPD Exacerbation

Congestive Heart failure

            Pneumonia

            Asthma

            Acute respiratory distress

Other treatment plan COPD exacerbation include Prednisone, Antibiotic for 7 days, steroid inhaler.

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Focused SOAP Note Template

Patient Information:

Initials: XYZ           Age: 65yo           Sex: Female

S.

CC: “Difficulty breathing.” Focused SOAP Note Template And Patient Information Case Study

HPI: The client, XYZ, presents to the clinic with difficulty breathing that has persisted for the last two weeks. She also reports a cough and shortness of breath. The client denies pain or recent respiratory illness, or infection. She further denies using alternative medications. XYZ reports a COPD history with symptoms worsening with activities. The client denies recent exposure to potential allergens nor travels to highly-polluted regions.

• Onset: 2 weeks ago
• Location: Respiratory system
• Duration of symptoms: The last two weeks
• Character of symptoms: Difficulty breathing
• Aggravating: Activities worsen COPD symptoms
• Relieving factors: None
• Temporal factors: Cough and shortness of breath
• Severity: Not stated Focused SOAP Note Template And Patient Information Case Study

Current Medications:

1. Tylenol 1000mg to relieve the pain,
2. Albuterol MDI 90 mcg/2 puff 6 hours as needed to alleviate COPD exacerbation,

• Omeprazole 40 mg daily

1. Ipratropium Bromide 2 puff every 6 hours as needed.

Allergies: Penicillin triggers a rash

PMHx: COPD, Osteoarthritis of knees and hands, and GERD

Soc & Substance Hx: The client smokes two packs of cigarettes daily. Her efforts to quit or reduce smoking nicotine gum have been unsuccessful. XYZ takes 1 to 2 alcoholic drinks weekly. She denies illicit drug usage.

Fam Hx: XYZ’s grandparents are deceased. Her mother died of cardiac arrest at 78. Her father lost his life in a car accident at 69 years. Her elder brother is alive at 73 years with hypertension and arthritis. Her younger sister, aged 57, has asthma diagnosed 8 years ago. Her youngest sister has fatty liver at 52 years. Her three children are alive at 30, 24, and 19 years. Her firstborn daughter had a breast tumor diagnosed 3 years ago. Her second-born daughter has had PCOS for 20 years. Her lastborn son does not have a known medical condition. Focused SOAP Note Template And Patient Information Case Study

Surgical Hx: The client reports cholecystectomy and appendectomy history.

Mental Hx: Denies history of psychiatric disorders

Violence Hx: Denies physical abuse

Reproductive Hx: She has three children. The client is currently sexually inactive.

ROS:

GENERAL: She denies fatigue.

HEENT: She denies head deformities. Denies eye discharge. Denies ear pain. Denies frequent sneezing. Denies bleeding gum or sore throat.

SKIN: Denies skin redness or itching.

CARDIOVASCULAR: XYZ denies chest discomfort or edema.

RESPIRATORY: XYZ reports difficulty breathing, shortness of breath, and cough.

GASTROINTESTINAL: Denies abdominal pain.

GENITOURINARY: XYZ denies painful urination.

NEUROLOGICAL: She denies numbness or paralysis

MUSCULOSKELETAL: The client denies back pain.

HEMATOLOGIC: She denies abnormal bleeding.

LYMPHATICS: XYZ denies splenectomy.

PSYCHIATRIC: Denies mood swings or suicidal thoughts.

ENDOCRINOLOGIC: XYZ denies polyuria

REPRODUCTIVE: The client is not sexually active.

ALLERGIES: Reports COPD exacerbations Focused SOAP Note Template And Patient Information Case Study

O.

Physical exam:

Vital Signs: BP 122/64, RR 26, Pulse rate 92, SpO2 89% on RA, Temp 98.9℉, and BMI 35.

GEN: XYZ is well-nourished. Dyspnea noted at rest. Purse lip and accessory muscles breathing noted. The client uses 3- word sentences to communicate. Acute distress was noted.

HEENT: Her head is normocephalic and atraumatic. Equal and round pupils with reactivity to light were noted. Her oropharynx is clear. No lesions were seen on her mouth. Clear tympanic membranes noted.

NECK: No thyromegaly seen on examination.

RESPIRATORY: Wheezing on expiration noted. Crackles were noted in her right upper lobe.

CARDIAC: S1 and S2 present. Regular cardiac rate and rhythm without gallops. No peripheral edema was noted. Pulses 2+/4 noted.

GI/GU: Tenderness with no masses noted. Active bowel sounds were noted in all quadrants.

SKIN: Warm to the touch without lesions or rashes.

Diagnostic results:

CBC: High haemoglobin levels and elevated C-reactive protein.

ABG: PaCO2 during follow-up

Chest x-ray: Enlarged lungs and a flattened diaphragm noted

A.

Differential Diagnoses

1. COPD Exacerbation – Primary diagnosis Focused SOAP Note Template And Patient Information Case Study
2. Congestive Heart failure

• Pneumonia

1. Asthma
2. Acute respiratory distress

COPD Exacerbation: This condition is usually triggered by an airway infection. It is characterized by airway inflammation, reducing oxygen levels in the body (Soler-Cataluña et al., 2022). The most common symptoms of COPD include shortness of breath, especially with physical activities, chest tightness, wheezing, chronic cough, usually with sputum production, reduced energy, oedema, and frequent respiratory infections (Soler-Cataluña et al., 2022). The client’s pertinent positives include difficulty breathing, cough, shortness of breath, wheezing, and crackling with expiration. Additionally, diagnostic test results, such as high haemoglobin levels, presence of PaCO2 during follow-up, and enlarged lungs, confirm COPD exacerbation. Lastly, the client reports a history of COPD. Therefore, COPD Exacerbation is the most pertinent primary diagnosis.

Congestive Heart failure: This condition is characterized by the inability of the heart to pump blood efficiently. The most common signs of heart failure include fatigue and dyspnea, reduced exercise tolerance, shortness of breath with lying down or activity, oedema, irregular or rapid heartbeat, wheezing, persistent cough, and abdominal swelling (Mulder et al., 2020). Pertinent positives include shortness of breath, cough, and wheezing. However, heart failure is dismissed due to several pertinent negatives, including dyspnea, irregular or rapid heartbeat, reduced exercise tolerance, oedema, and swelling around her belly. Focused SOAP Note Template And Patient Information Case Study

Pneumonia: The most common symptoms include chest pain, mental awareness changes in elderly adults, cough with sputum, fatigue, sweating, fever, shaking chills, lower body temperature in geriatrics, shortness of breath, diarrhoea, nausea and vomiting, and wheezing (Marchello et al., 2019). The client’s pertinent positives include wheezing, shortness of breath, and wheezing. However, this condition is ruled out due to multiple pertinent negatives such as sputum production, fatigue, fever or chills, or abdominal symptoms.

Asthma: Asthma exacerbations occur with exposure to allergens or triggers. The most common symptoms include wheezing with exhalation, coughing, and difficulty sleeping due to shortness of breath, wheezing, or coughing (Ramsahai et al., 2019). Pertinent positives include coughing, wheezing, and shortness of breath. However, this condition is ruled out since the client denies exposure to potential triggers.

Acute respiratory distress is primarily characterized by rapid and laboured breathing with a fast pulse rate. Other common symptoms are general weakness, muscle fatigue, low blood pressure, discoloured nails, a dry cough, fever, and headaches (Matthay et al., 2019). The client’s pertinent positives include difficulty breathing and cough. However, the clinician disqualifies acute respiratory distress due to several negative pertinent such as muscle fatigue, headache, low blood pressure, or fever. Focused SOAP Note Template And Patient Information Case Study

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The client’s treatment therapy includes medications and non-pharmacological interventions. The client should be administered O2 at 2L to boost the saturation level. Spirometry with Pulmonologist is also recommended once the patient is stable. Additionally, the client should be administered Albuterol 4 mg orally four times daily. Albuterol is recommended due to its efficacy in managing COPD exacerbations (Hodroge et al., 2020). The client should also be given prednisone 20mg PO. The clinician should also be prescribed Cefuroxime 250 mg orally twice daily for seven days. A steroid inhaler of 2 puffs (168 mcg) twice daily should also be recommended. Lastly, the client should be educated on the significance of smoking cessation in preventing COPD exacerbations once ready.

References

Hodroge, S. S., Glenn, M., Breyre, A., Lee, B., Aldridge, N. R., Sporer, K. A., … & Gilbert, G. H. (2020). Adult patients with respiratory distress: current evidence-based recommendations for prehospital care. Western Journal of Emergency Medicine, 21(4), 849.

Marchello, C. S., Ebell, M. H., Dale, A. P., Harvill, E. T., Shen, Y., & Whalen, C. C. (2019). Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: a systematic review and meta-analysis. The Journal of the American Board of Family Medicine, 32(2), 234–247.

Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., … & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature Reviews Disease Primers, 5(1), 18.

Mulder, B. A., van Veldhuisen, D. J., & Rienstra, M. (2020). What should the C (‘congestive heart failure’) represent in the CHA2DS2‐VASc score? European Journal of Heart Failure, 22(8), 1294.

Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423-432.

Soler-Cataluña, J. J., Piñera, P., Trigueros, J. A., Calle, M., Casanova, C., Cosío, B. G., … & representing the GesEPOC 2021 working group. (2022). [Translated article] Spanish COPD guidelines (GesEPOC) 2021 update. Diagnosis and treatment of COPD exacerbation syndrome. Archivos de bronconeumologia, 58(2), T159-T170. Focused SOAP Note Template And Patient Information Case Study