Case Study Soap Note Assignment Paper

*Patient Information: E. S. is a 69-year-old African-American male

Subjective:

CC (chief complaint): “I started coughing badly a few days ago and I feel hot, but now it hurts when I take a deep breath.”

HPI: E.S is a 69-year-old African American male that came to the unit with complaints of bad cough and chest pains, which started a few days ago. The patient reports that he feels pain when he takes a deep breath. The cough is productive. The pain does not radiate. The accompanying symptoms include fever, chills, pain with inspiration, fatigue, and a decrease in appetite. The problem started three days ago following his participation in an outdoor camping trip. The patient has been using Tylenol, which is associated with minimal pain relief, and teas to loosen phlegm. The chest pain worsens when he engages in exercises and when he lies down. The client’s self-rated pain on a pain rating scale (0-10) is 5/10.

Location: chest

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Onset: 3 days ago

Character: productive cough with sputum and pain upon inspiration

Associated signs and symptoms: fever, chills, pain with inspiration, pain that does not radiate, decreased appetite, fatigue.

Timing: started 3 days ago after participating in an outdoor camping trip

Exacerbating/ relieving factors: pain with inspiration coughs worse with lying down and exercise, minimal relief with Tylenol, drinking teas to loosen phlegm.

Severity: moderate to severe cough, pain during inspiration at 5/10

Current Medications: The client reports the use of Tylenol 1 gm TDS for pain management. He also takes green tea to help him loosen phlegm.

Allergies: The patient denies any history of food and drug allergy. He is allergic to pollen.

PMHx: The client has no history of hospitalizations. The client denied any history of blood transfusion or surgery. His immunization records are up-to-date.

Soc Hx: The client is a retired truck driver. He is married with three children. He is a non-smoker. He denied alcohol or tobacco use. He reported that he drives himself and wears a safety belt. He lives in a healthy environment with adequate sanitation.

Fam Hx: The patient reported a history of depression, diabetes, and hypertension in the family. His deceased father was diagnosed with depression and hypertension. His mother died of diabetes. His wife is diabetic and is currently in treatment. The children do not have any history of chronic or heritable disease.

ROS:

GENERAL: Reports fever, chills, fatigue, and anorexia. Denies night sweats or changes in weight.

EYES: The client denied vision changes, drainage, pain, or double vision. He does not use corrective lenses.

EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. He also denied nasal congestion, drainage, and nose bleeds. He also denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.

CARDIOVASCULAR: The client denied chest pain and palpitations.

PULMONARY: The client reported chest pain, productive cough, and pain with inspiration. He denied dyspnea, cyanosis, and wheezing.

GASTROINTESTINAL: The client denied abdominal pain, tenderness, constipation, diarrhea, and bloating.

GENITOURINARY: The client denied urinary incontinence, increased urgency, painful urination, hematuria, and abnormal smell of urine.

MUSCULOSKELETAL: The patient denied muscle pain, difficulties in walking, fractures, muscle tenderness, and muscle weakness.

INTEGUMENTARY: The client denied rashes, lumps, bruises, and lacerations.

NEUROLOGICAL: The client denied upper arm tremors, loss of consciousness, headache, slurred speech, vomiting, and nausea.

PSYCHIATRIC: The client denied any history of mental illness in his immediate family members.

ENDOCRINE: The client denied heat or cold intolerance, changes in body weight, polyuria, polydipsia, and polyphagia.

HEMATOLOGIC/LYMPHATIC: The patient denied lymphadenopathy.

ALLERGIC/IMMUNOLOGIC: The client denied any history of food or drug allergy. He reported an allergy to pollen.

Objective.:

Vital signs: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94% on R.A, Ht: 5’10”, Wt: 154 lbs, BMI: 22.10

General: Healthy elderly male, alert & Ox4, pleasant, appears with no distress, and answers questions relevantly, but appears lethargic.

Respiratory: There is the presence of rales and rhonchi on auscultation, more pronounced in the LLL, increased fremitus, and dullness to percussion. There is the absence of chest indrawing and the use of respiratory muscles during breathing. There is also the absence of nasal flaring.

Diagnostic tests & results: One of the laboratory investigations that were requested for the client is a blood test. A complete blood count (CBC) was requested to determine the cause of the infection. The results showed the elevation of white blood cells, which indicated the cause of the problem to be bacteria. A chest x-ray was also requested. The diagnostic investigation aimed to determine the location of the infection and the extent of its effect on the lungs. A chest x-ray is also aimed at ruling out any other cause such as tumors, which could be contributing to symptom development. The results of the chest x-ray showed consolidation in the left lower lobe of the left lung. Throat culture was also performed. A throat swab was taken for laboratory analysis to determine the presence of group A streptococcus, which causes strep throat, scarlet fever, and pneumonia. The laboratory results were positive for group A streptococcus. Sputum was also taken for culture and sensitivity analysis. The aim was to determine the causative organism for the infection. Blood culture was done to guide the determination of the accurate antibiotic needed for disease management. Bronchoscopy was not done since the client was not admitted to the hospital.

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Assessment:

Pneumonia due to Streptococcus pneumoniae- ICD-10 code: J13: The client’s primary diagnosis is pneumonia caused by Streptococcus pneumoniae. Streptococcus pneumoniae is a gram-positive bacteria that is responsible for causing bacteria-related pneumonia. The bacteria are mainly spread through inhalation of the respiratory droplets from an infected person. Patients experience symptoms that include chest pain, shortness of breath, fever, cough, and chills when it affects the respiratory system (Jean et al., 2020). Pneumonia due to Streptococcus pneumoniae is the primary diagnosis due to its presenting symptoms as well as confirmation by laboratory investigations that include complete blood count, throat culture, blood culture, and sputum test.
Pneumonia, viral: Pneumonia due to a viral cause is the secondary diagnosis that should be considered for this patient. Viral pneumonia is attributed to viruses that include influenza, which can affect the lungs. Factors that include depressed immunity, the elderly, and chronic conditions predispose patients to the disease. Patients often experience symptoms that include fever, sore throat, dry cough, loss of appetite, and muscle pain (Gu et al., 2020). Viral pneumonia is, however, the least possible cause for E.S’s problem due to sputum, blood, and throat swab tests confirming its cause to be bacteria. In addition, the patient does not exhibit symptoms associated with viral pneumonia such as dry cough, muscle pain, headache, and sore throat.

Bronchitis: Bronchitis is the other secondary diagnosis to be considered for the patient. Bronchitis is a respiratory infection that is characterized by the inflammation of the bronchial tubes. The inflammation may be attributed to factors such as bacterial or viral infections and lifestyle behaviors that include smoking. Patients with bronchitis experience symptoms that include chest pain, fever, chills, shortness of breath, fatigue, cough, headaches, and body aches (Legnardi et al., 2020). Despite the similarities in symptoms, E.S. is not suffering from bronchitis due to the absence of bronchial tubes, as seen from the results of the chest x-ray. The patient also has an infection of one lung, which is not associated with bronchitis.
COPD: Chronic obstructive pulmonary disease (COPD) is the other diagnosis that should be considered for the patient. COPD is a disease characterized by the inflammation of the respiratory system, which impedes airflow from the lungs. Patients experience symptoms that include cough, chest pain, dyspnea, wheezing, and productive cough. Factors that include exposure to irritants such as smoke and gases contribute to the development of COPD (Hikichi et al., 2018). However, COPD is the least likely cause of E.S’s problem due to positive throat, blood, and sputum test for bacterial pneumonia.
Pulmonary edema: Pulmonary edema is the other differential that may be considered for the patient. Pulmonary edema arises from excessive fluid accumulation in the lungs. It mainly arises from heart problems such as hypertension and heart failure (Chamarthy et al., 2018). Pulmonary edema is the least likely cause due to the absence of cardiovascular complications, which may contribute to its development.

Plan:

Pharmacological Intervention: Ciprofloxacin 400 mg IV q8hr 10 days, Tylenol 1 gm q8hr 5 days

Non-pharmacological Interventions: Deep breathing exercises, relaxation techniques, and effective coughing techniques

Referrals: none

Consults: Respiratory therapist

Health Maintenance: healthy, balanced nutrition, maintaining active physical activity, avoiding smoking and alcohol, and coughing hygiene

Patient Education: Treatment adherence, healthy lifestyles and behaviors, adverse effects of the treatment, and avoiding over-the-counter medications

Follow-up visit if needed: Follow-up after 2 weeks

Reflection Statement: I believe that the developed diagnosis for the client is accurate. Laboratory and diagnostic investigations support the reached diagnosis. The adopted treatment is also appropriate, as it is evidence-based. One thing that I would do if I encounter a similar patient in the future would be admitting for further observation and management. Admitting the patient will also enable the determination of response to the adopted treatments.

References

Chamarthy, M. R., Kandathil, A., & Kalva, S. P. (2018). Pulmonary vascular pathophysiology. Cardiovascular Diagnosis and Therapy, 8(3), 208–213. https://doi.org/10.21037/cdt.2018.01.08

Gu, X., Zhou, F., Wang, Y., Fan, G., & Cao, B. (2020). Respiratory viral sepsis: Epidemiology, pathophysiology, diagnosis and treatment. European Respiratory Review, 29(157). https://doi.org/10.1183/16000617.0038-2020

Hikichi, M., Hashimoto, S., & Gon, Y. (2018). Asthma and COPD overlap pathophysiology of ACO. Allergology International, 67(2), 179–186. https://doi.org/10.1016/j.alit.2018.01.001

Jean, S.-S., Chang, Y.-C., Lin, W.-C., Lee, W.-S., Hsueh, P.-R., & Hsu, C.-W. (2020). Epidemiology, Treatment, and Prevention of Nosocomial Bacterial Pneumonia. Journal of Clinical Medicine, 9(1), 275. https://doi.org/10.3390/jcm9010275

Legnardi, M., Tucciarone, C. M., Franzo, G., & Cecchinato, M. (2020). Infectious Bronchitis Virus Evolution, Diagnosis and Control. Veterinary Sciences, 7(2), 79. https://doi.org/10.3390/vetsci7020079

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Which bacteria is the leading cause of pneumonia and the one that he most likely has? Streptococcus pneumoniae
What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae? The patient does not have a history of depressed immunity (Jean et al., 2020)
In this type of pneumonia, the sputum analysis indicates gram __positive_______ (negative/positive) diplococci. There are also a large number of _______serotypes________.
What other bacteria must be considered? Group A Streptococcus, Staphylococcus aureus, and Klebsiella spp.
What is the best way to identify the pathologic agent? Culture negative DBS
The best sputum sample comes from the saliva in the mouth. TRUE OR FALSE False
When is the best time to get a sputum sample? Why is that the best time? When one first wakes up because of the overnight accumulation of lung secretions
When sending the sputum to the lab, how does the lab determine it is an adequate sample?) By determining if the required sample levels have been collected according to sample tube calibrations
Name four other diagnostics that can be done on this patient to further understand his condition. Sputum test, chest x-ray, pulse oximetry, CT scan, and pleural fluid culture (Gu et al., 2020)
If obtaining blood cultures, how many sets are typically obtained? At least two sets
When choosing an antibiotic to treat this pt, it is important to try to cover for all pathogens, especially gram-negative organisms. True
When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months? Antibiotics
Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the rx directions the way with the med and the sig how you would write it for the pt. PO Amoxicillin 500 mg TDS for seven days
The choice of antibiotic therapy depends on three Important factors. What are they? Illness severity, patient’s age, organ function status, history of drug allergies, comorbid conditions, and laboratory abnormalities
In most cases, improvement is seen within ____24______ to _____48____ hours of initiation of antibiotics
Should cough medicine be recommended? ____no___ Why or why not? It masks changes in symptoms associated with pneumonia
Name two teaching points to tell the patient. Treatment adherence, cough hygiene, and importance of healthy, balanced diet.

References

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CASE STUDY /PROCEDURES: week 6
If information is not provided, make up or create the information in order to make your note complete. I should not see “unknown,” “information not given,” or “N/A” in your note! But you can put “none” if documented. For example, allergies -no allergies to medications.
For the SOAP note, you are expected to have an APA formatted title page, page numbers throughout, in-text citations, and references.
1. CASE STUDY for SOAP note : Follow template provided for SOAP note
*Patient Information: E. S. is a 69-year-old African-American male
Subjective:
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – “I started coughing badly a few days ago and I feel hot, but now it hurts when I take a deep breath.”
HPI: Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (69 year old African-American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. Use the following info below to write the HPI in paragraph form:
Location: chest
Onset: 3 days ago
Character: productive cough with sputum and pain upon inspiration
Associated signs and symptoms: fever, chills, pain with inspiration, pain does not radiate, decreased appetite, fatigue.
Timing: started 3 days ago after participating in an outdoor camping trip
Exacerbating/ relieving factors: pain with inspiration, coughs worse with lying down and exercise , minimal relief with Tylenol, drinking teas to loosen phlegm.
Severity: moderate to severe cough, pain during inspiration at 5/10

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed- Denies any medical history or surgeries.
Soc Hx: include occupation (student) and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system. Non-smoker, denies alcohol or tobacco use.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
GENERAL: Reports fever, chills, fatigue, anorexia. Denies night sweats or changes in weight.
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
PSYCHIATRIC:
ENDOCRINOLOGIC:
ALLERGIES:
Objective.:
Vital signs: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94% on R.A, Ht: 5’10”, Wt: 154 lbs, BMI: 22.10
((Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. ))
General: Healthy elderly male, alert & Ox4, pleasant, appears with no distress, & answers questions relevantly, but appears lethargic.

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HEENT:
Cardiovascular:
Respiratory: rales and rhonchi, more pronounced in the LLL, increased fremitus and dullness to percussion
GI:
Diagnostic tests & results: Include any labs, x-rays, or other diagnostics and results that are needed to develop the differential diagnoses (support with evidence and guidelines) and results that support the primary diagnosis of bacterial Pneumonia.
CBC-
CXR- reveals a consolidation in the left lower lobe.
Throat culture-
Sputum Gram stain-
Blood cultures-
Bronchoscopy-(only if admitted to hospital)- not done in clinic.
Assessment:
Differential Diagnoses (list 4 other differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
1. Pneumonia due to Streptococcus pneumoniae- ICD-10 code: J13
2. Pneumonia, viral
3. Bronchitis
4. COPD
5. Pulmonary edema
Plan:
Pharmacological Intervention:
Non-pharmacological Interventions:
Referrals:
Consults:
Health Maintenance:
Patient Education:
Follow-up visit if needed:
Reflection Statement:
References
You are required to include at 4 evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostic tests and differentials diagnosis.

2. Please answer the questions in a separate document from the SOAP note and attach.

1. Which bacteria is the leading cause of pneumonia and the one that he most likely has?
2. What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae?
3. In this type of pneumonia, the sputum analysis indicates gram _________ (negative/positive) diplococci. There are also a large number of _______________.
4. What other bacteria must be considered?
5. What is the best way to identify the pathologic agent?
6. The best sputum sample comes from the saliva in the mouth. TRUE OR FALSE
7. When is the best time to get a sputum sample? Why is that the best time?
8. When sending the sputum to the lab, how does the lab determine it is an adequate sample?)
9. Name four other diagnostics that can be done on this patient to further understand his condition.
10. If obtaining blood cultures, how many sets are typically obtained?
11. When choosing an antibiotic to treat this pt, it is important to try to cover for all pathogens, especially gram-negative organisms.
12. When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
13. Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the rx directions the way with the med and the sig how you would write it for the pt.
14. The choice of antibiotic therapy depends on three Important factors. What are they?
15. In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics
16. Should cough medicine be recommended? _______ Why or why not?
17. Name two teaching points to tell the patient. **** Use APA style. **** Provide 4-5 scholarly references to complete SOAP and questions.

Case Study Soap Note Assignment Paper