Preceptorship Experience: SOAP Note Essay.

Preceptorship Experience: SOAP Note

Subjective

The chief complaint of the patient was a productive cough and chills accompanied by fever for five days. The patient was a 45 year-old Caucasian male who described the cough as accompanied by pleuritic pain and aggravated by attempts at laying supine. It was reduced by drinking warm lemon juice and was rated by the patient at 7/10. The patient stopped smoking five years ago but still drinks alcohol at least three times a week (Bickley, 2017).Preceptorship Experience: SOAP Note Essay.

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Objective

            The patient appeared lethargic at the ER but was alert. He had no difficulties walking and his gait showed no abnormalities. His temperature was 38.7°C, BP 125/85 mmHg, RR 16/ min, PR 78 b/m, and SpO₂ 92%. Diagnostic imaging of the chest with CXR showed lobar consolidation especially on the left lower lung. There was a decrease in breath sounds and crackles were audible through auscultation. Pertinent positives included some use of accessory muscles of breathing, fever, cough, consolidation on CXR, and low oxygen saturation. Pertinent negatives included lack of hemoptysis and lack of lymphadenopathy (Hammer & McPhee, 2018).Preceptorship Experience: SOAP Note Essay.

Assessment

The meaning of the consolidation seen in the CXR is that this male had lobar pneumonia which was community-acquired. It is most likely caused by Streptococcus pneumoniae and the most likely differential diagnosis is tuberculosis (Hammer & McPhee, 2018).   The CXR finding impacts treatment because it means an antibiotic must be given as soon as possible.Preceptorship Experience: SOAP Note Essay.

Plan

The plan was to start the patient on oral clavulanate-potentiated amoxicillin, to give supplemental oxygen by nasal prongs, to hydrate by giving enough oral fluids, and to give Tylenol for the fever (Katzung, 2018).Preceptorship Experience: SOAP Note Essay.