Assignment: Academic SOAP Note

Assignment: Academic SOAP Note

Assignment: Academic SOAP Note

Reason for Follow-Up: The patient is being followed-up at the inpatient medical unit on the second day after admission following an impression of COPD exacerbation.

Clinical Course Summary: D.L. is a 68-year-old Caucasian male who presented to the ED one day ago with a chief complaint of shortness of breath (SOB) and chest tightness. He reported that he had a cough with sputum production for about 8 weeks and was taking OTC expectorant syrups, but the cough was not improving. The cough worsened, and he started experiencing dyspnea, and chest tightness, which he was concerned could be a heart attack. The patient has a history of smoking 1-2 PPD. The attending physician conducted a Pulmonary Function test in the ED, and the results were:  Before administering Albuterol: FEV1- 50%; FEV1/FVC- 60%; After administering Albuterol: FEV1- 50%; FEV1/FVC- 60%. The patient was diagnosed with COPD based on the presenting symptoms and Pulmonary Function test results. The patient is on his second day of admission at the medical unit.

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Review of systems:

General:  Reports weight loss of about 10 pounds in the past four months; Reduced energy levels. Denies fever, chills, or malaise.

HEENT: Head: Denies headache or head injury. Eye: Negative for vision changes, eye pain, blurred vision, or double vision. Ear: Denies tinnitus, hearing loss, or ear discharge. Nose: Denies sneezing, rhinorrhea, or nasal discharge. Throat: Denies throat pain, sore tongue, or hoarseness.

Respiratory: Reports shortness of breath, cough, chest tightness, sputum production, and wheezing.

Cardiovascular: Reports SOB and chest tightness. Negative for palpitations or edema.

Musculoskeletal: Denies joint pain, joint stiffness, muscle pain, or limitations in movement.

Physical Exam:

Vital Signs: BP- 130/84; HR-98; RR- 24; Temp- 98.4; SPO2-90

HT- 5’6 WT- 160lb; BMI- 25.8

General:  Caucasian male patient in his 60s. The patient is alert but in mild distress and appears anxious. He is neat and appropriately dressed and displays appropriate mannerism. He maintains adequate eye contact, and his speech is clear and logical.

HEENT: Head: Symmetrical and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; No excessive lacrimation; PERRLA. Ears: Tympanic membranes are shiny and intact. Nose: Pink and moist mucous membranes; The nasal septum is well-aligned. Throat: Tonsillar glands are non-erythematous.

Respiratory: Barrel chest; Accessory muscles used when breathing in; Prolonged expiration; Bilateral wheezes during forced and unforced expiration; Diffusely reduced breath sounds; Hyperresonance on percussion.

Cardiovascular: No edema or distention of neck veins; Distant heart sounds; No S gallop or heart murmurs.

Musculoskeletal: Normal gait and posture; Mild muscle wasting; Full ROM in all joints; Muscle strength- 5/5.

Laboratory and Radiology Results:

Pulmonary function test: Before administering Albuterol: FEV1- 50%; FEV1/FVC- 60%; After administering Albuterol: FEV1- 50%; FEV1/FVC- 60%.

Assessment

Differential diagnoses:

Asthma: The classic presentation of asthma includes dyspnea, cough, and wheezing. Other clinical manifestations include chest tightness or pain, bradycardia, SPO2 <92%, cyanosis, and confusion. Asthma is a differential diagnosis for this patient owing to positive symptoms of dyspnea, cough, chest tightness, wheezing, SPO2 of 90%, and FEV1/FVC of 60% (Bush, 2019). The FEV1/FVC ratio in asthma usually improves with Albuterol administration. However, the ratio did not improve in this patient ruling it out as a primary diagnosis.

Congestive heart failure (CHF): The clinical manifestations of CHF include dyspnea on exertion, chest pressure/tightness, wheezing, nocturnal cough, fatigue, body weakness, anorexia, and weight loss. Common findings on physical exam include neck vein distension, cyanosis, tachycardia >120, wheezing, rales, S3 gallop, and fine basal crackles on chest auscultation (Schwinger, 2021). The patient presented with SOB, chest tightness, low energy levels, cough, wheezing, weight loss, bilateral wheezing, and distant heart sounds, which led to a differential diagnosis of CHF.

Acute and chronic medical conditions:

Chronic Obstructive Pulmonary Disease (COPD): The triad clinical presentation of COPD includes dyspnea on exertion, cough, and sputum production. Other clinical manifestations include tachypnea, cyanosis, use of accessory respiratory muscles, wheezing, and weight loss (Lief & McSparron, 2019). Pertinent respiratory exam findings include a hyperinflated or barrel chest, pursed-lip breathing, prolonged expiration, decreased breath sounds, wheezing, hyper resonance on percussion, coarse crackles, and peripheral edema (Lief & McSparron, 2019). The patient has a history of smoking which increases his risk for COPD. He presented with symptoms consistent with COPD, like SOB, cough, sputum production, chest tightness, wheezing, and weight loss. The FEV1/FVC ratio of 60% that did not improve with Albuterol pointed to COPD. Furthermore, physical findings were consistent with COPD like a high respiratory rate, use of accessory respiratory muscles, prolonged expiration, barrel chest, pursed-lip breathing, wheezing on auscultation, reduced breath sounds, and hyper resonance on percussion.

Treatment Plan:

Diagnostics: A chest x-ray will be requested to rule out other respiratory diseases and monitor the patient’s progress with treatment (Bollmeier & Hartmann, 2020).

Medications: Medications will aim to alleviate COPD symptoms, correct airflow limitation, and improve oxygenation.

Ipratropium inhaler 2 actuations every 6 hours.

Salmeterol 1 inhalation BD

Amoxicillin 500 mg TDS. The patient’s purulent sputum will require antibiotic therapy to treat any underlying respiratory infection (Bollmeier & Hartmann, 2020).

Consultations: Consult a chest physiotherapist to plan the patient’s pulmonary rehabilitation care (Fu et al., 2022).

Consultation with a nutritionist for nutritional support and creating a diet plan to prevent muscle wasting.

Health education topics: Health education will include educating the patient on the benefits of smoking cessation in delaying the progress of COPD and preventing exacerbations. He will be advised to avoid environmental pollutants since they trigger exacerbations (Fu et al., 2022). The patient will be recommended to engage in moderate aerobic exercises to improve pulmonary function.

Discharge plan: The patient will be discharged when the COPD symptoms abate and SPO2 is constantly above 95%. He will be instructed on medication compliance to prevent COPD exacerbations. Besides, he will be registered for a pulmonary rehabilitation program, which will take place in the outpatient setting (Fu et al., 2022). He will be scheduled for a follow-up visit at the outpatient clinic after four weeks to monitor his progress with treatment.

Geriatric Considerations: COPD treatment is similar for all adults across the lifespan. Thus, the treatment interventions would have been similar if the patient had been younger.

References

Bollmeier, S. G., & Hartmann, A. P. (2020). Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists, 77(4), 259–268. https://doi.org/10.1093/ajhp/zxz306

Bush, A. (2019). Pathophysiological Mechanisms of Asthma. Frontiers in pediatrics, pp. 7, 68. https://doi.org/10.3389/fped.2019.00068

Fu, Y., Chapman, E. J., Boland, A. C., & Bennett, M. I. (2022). Evidence-based management approaches for patients with severe chronic obstructive pulmonary disease (COPD): A practice review. Palliative medicine, 36(5), 770–782. https://doi.org/10.1177/02692163221079697

Lief, L., & McSparron, J. (2019). Acute Exacerbation of COPD. Evidence-Based Critical Care: A Case Study Approach, pp. 169–173. https://doi.org/10.1007/978-3-030-26710-0_22

Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular diagnosis and therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302