Keew Xis

● To Prepare:

○ Review this and previous weeks’ Learning Resources as needed.

○ Review the case study provided. Based on the provided patient information, think about the health history you would need to collect from the patient.

○ Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. Reflect on how the results would be used to make a diagnosis.

○ Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.

○ Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.

○ Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with their condition(s).

● Case study for Week 6

Remember that this is a mock patient. You will make up the history and exam findings as if you have interviewed this patient and performed an exam. You are required to use a SOAP note template with citations and references in APA format. You will include three ddx with supportive documentation, citations, and references! If the information was not provided in the case study, be creative and ask yourself what would be important for me to ask this patient if he were in my office. What systems should I include in the ROS and for the Exam? Hint: You will always, always have the heart, lungs, HEENT, and abdomen in a patient with these symptoms. What else is important?

Use the following case to complete a focused SOAP note:

Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot.” He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm.

Edwin is a nonsmoker and non-drinker. He has been very healthy and has no medical problems. He has never had surgery.

On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.

Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia.

For this SOAP note, please write out each question/answer (1-17) and provide the answers at the end of your SOAP note. Do not incorporate the answer into the note, but rather answer the question in question/answer format.

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, does the sputum analysis indicate gram positive or negative diplococci? There would also be a large number of _________?

4. What other bacteria must be considered?

5. What is the best way to identify the pathologic agent?

6. Where does the best sputum sample come from?

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 patient, it is important to try to cover for all pathogens, especially gram-negative organisms. True or false?

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?

17.Name two patient education points you would share with this patient This announcement is closed for comments