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SOAP Note.

Name: Lauretta Onwukwe

Date: 03/19/2014 Date of Encounter: 03//2014

Faculty: Ms. Sonstein Location of Encounter: Emmason Pediatric and Family Clinic.

Identifying Information:

Patient’s Initials JS

DOB (Age) 02/19/1946, 68yrs

Gender /Race Male, African American

Chief Complaint: “I have cough and trouble breathing for almost 2 weeks now”

HPI: Pt is a 67yr old African American male who present with persistent shortness of breath, cough, and increased sputum production. Pt states ‘“sometimes I feel breathlessness” and unable to climb up to three flight of steps. Pt states shortness of breath started about two weeks ago. Pt states he could not remember anything that could have triggered the exacerbation as he always take his medication and following instructions by the doctor. Pt states his inhaler-salmeterol is not helping him at all. Pt with increased purulent sputum production, pleuritic pain, and fatigue. States unable to “catch breath” is bothering him hence the office visit. Pt currently denies any chest pain, fever, hemoptysis, and dysuria.

Medical Hx. HTN, diabetes, hypercholesterolemia, anxiety, arthritis

Allergies: NKDA

Medications:

Salmeterol inhaler 50mcg 1 puff BID

Novolog insulin, 30 units SQ before breakfast and 35 units before dinner.

Metformin 1000mg PO BID

Metoprolol 50 mg PO daily.

Simvastatin 20 mg PO QHS.

xanax 0.25 mg PO q12 PRN anxiety.

Miralax 17mg PO daily PRN constipation.

Tramadol 50 mg PO Q8 hrs PRN pain

Immunization: Up to date. Had pneumococcal vaccine last year

Last Physical exam: Jan, 2013, prostate screening was done, states performing testicular exam occasionally unremarkable.

Nutrition: Has poor appetite since the onset of present exacerbation otherwise eats 3 meals/day, snacks, and fruits and vegetables.

Exercise: walks in the park with spouse and friends for 30 mins three times a week

Relevant Past Medical History: Asthma, diabetes HTN

General Health: patient looks tired and stressed but well groomed

Surgeries: Rt hip hemiarthroplasthy 2010 due to hip fracture secondary to fall, appendectomy-1994

Blood transfusions: N/A

Hospitalizations: 01/20/2013 due to pneumonia

Serious Accidents/Injuries/Fractures: Rt hip fracture secondary to fall

Major Illnesses (including psychiatric): Anxiety, on xanax, diabetes, controlled with insulin and oral hypoglycemic med

Childhood Illnesses: unable to recall

Social HX. A retired high school teacher lives with his spouse in a two story building. No pets in the home. Pt denies any financial problem, states his house has been paid for and has Medicare for health insurance. Pt is a smoker, smokes 5 sticks of cigarette/day, drinks red wine occasionally, denies use of any illicit drugs or consumption of alcohol

.Family HX: Father had COPD and lung cancer, mother - chronic bronchitis, two brothers positive for COPD and “heart disease”.

Patient Exploratory Model: "I think I have infection".

Impact on lifestyle: Insomnia, loss of appetite and inability to perform ADL due to shortness of breath and fatigue.

ROS of Relevant Systems

Head and neck: denies any headache or neck pain

Eyes: denies any watery eyes, itching, redness, or discharge.

Ears: denies earache or discharge.

Nose: No running nose and nasal congestion

Throat and mouth: reports occasional throat pain otherwise, no problem.

CV: reports chest pain when coughing, no edema

Lungs: Reports occasional wheezes

GI: reports hx of constipation, on miralax, occasional nausea

GU: denies any problem urinating or dysuria

Musculoskeletal: reports mild joint pain, no swelling.

Neuro/Psych: denies any numbness or tingling to extremities.

Lymph: Denies any swelling.

Physical Exam:

General: Mr. Joe is well groomed, looks tired otherwise in no acute distress.

Vital signs:

Ht: 5”6”

Wt: 158lbs

BMI- 25.5

BP-130/68

Pulse- 99.

Temp-98.4f.

Resp-24

SPO2-95% in room air

HEENT: Head normacephalic, no lesion.

Eye: Symmetrical, EOM wnl

Pinna normal, no lesion noted. TM- no bulging or erythema

Eye: symmetrical, EOM normal. No retinopathy

Neck: supple, midline trachea.

Lymph nodes: No lymphadenopathy.

Lungs: mild crackle to bilat lower lobes, dullness on percussion.

Cardiovascular: Normal S1 and S2. No murmurs or abnormal sound. Pulses palpable.

Abd: Soft, non tender, BSx4, no hepatosplenomegaly

Musculoskeletal: Active ROM, normal gait.

Skin: Warm to touch, no rashes noted and no clubbing

Neurologic: AOx3 and cooperative.

Pertinent positive: hx COPD, increased productive cough, increased dyspnea, tachypnea adventitious breath sound, purulent sputum, pleuritic pain, fatigue, hx of bronchodilator use, hx of smoking, family hx of COPD

Pertinent Negative: Absence of fever, barrel chest, use of accessory muscle for breathing. No purse-lipped breathing no cyanosis, and no peripheral edema, no confusion.

Lab. test:

COPD Assessment test (CAT): It is a measure of health status impairment in COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2013)

-Spirometry: Is not reliable during exacerbation, hence not done.

-Oximetry: To measure oxygen saturation in the blood. It can be useful in finding out whether oxygen treatment is needed, but it provides less information than the arterial blood gas test. (GOLD, 2013)

-Chest X-ray: helps to rule out other conditions with similar symptoms such as lung cancer and CHF.(GOLD, 2013)

-CBC: May help to identify polycythemia, anemia, or leukocytosis. . (GOLD, 2013)

DX:

1. -Acute COPD exacerbation: An exacerbation of chronic obstructive pulmonary disease (COPD) causes an acute deterioration of respiratory symptoms, particularly increased breathlessness and cough, and increased sputum volume and/or purulence. (GOLD 2013)

Differential Dx:

2. -Pneumonia: Due to productive cough, pleuritic pain, and dyspnea. . (Dains, Baumann, & Scheibel, 2012).

3. Lung cancer: Pt is a smoker and smoking is one of the risk factors for lung Ca. . (Dains, Baumann, & Scheibel, 2012).

4.CHF: Due to increased dyspnea and fatigue but ruled out due to absence of BLE edema (GOLD, 2013)

5.Chronic Bronchitis exacerbation: Due to increased dyspnea, cough, and sputum. . (Dains, Baumann, & Scheibel, 2012).

Plan:

-Salbutamol (albuterol) MDI inhaler 2 puff Q 4hrs. Short acting beta2-agonist with or without short-acting anticholinergic is the preferred bronchodilator for the treatment of exacerbation of COPD exacerbation management. (GOLD, 2013).

-Prednisolone 30mg PO daily for 14days. There is an indication that systemic corticosteroids in COPD exacerbation shortens recovery time, improves long function, and arterial hypoxemia (GOLD, 2013).

-Levaquin 250 mg PO daily x 5days Antibiotics should be given to patients with exacerbations of COPD who have three cardinal symptoms-increase in dyspnea, increase sputum, and increased purulence. Antibiotics can shorten recovery time and improve long function.(GOLD, 2013).

- Educated on smoking cessation: Smoking is one of the leading cause of COPD and quitting smoking will enhance and improve quality of life of COPD patient.(GOLD, 2013).

-Encouraged adequate fluid intake for good hydration. Depending on the condition of the patient, an appropriate fluid balance should be considered. .(GOLD, 2013).

-Encouraged to take all meds as prescribed and discussed importance of med compliance.

F/U: Return to clinic in 2 weeks or earlier than two weeks if symptoms get worse.

Reference:

Dains, J.E, Baumann, L. C, & Scheibel, P (2012). Advanced health assessment and clinical diagnosis in

primary care. St Louis, Missouri: Elsevier

GOLD (2013). Global strategy for the diagnosis, management and prevention of COPD. Retrieved from



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