SOAP NOTE

1

2

Academic Clinical SOAP Note

Muhammad Aftkhar

Grand Canyon University

January 25th, 2021

Academic Clinical SOAP Note

Subjective

Chief complaint

A 62 years old male was brought to the ED by his wife with a three-day history of short breathing, wheezing, grunting, nose flaring, productive cough, and gradual change in the color of sputum from yellow to brown (Fermont et al., 2020).

Primary working diagnosis

· COPD acute exacerbation (J44.1)

Acute exacerbation of chronic obstructive pulmonary disease manifests a sudden worsening of coughing symptoms, wheezing, fatigue, color, quantity, and sputum consistency. These symptoms typically last for several days and cause extreme discomfort to the patient.

Pending differential diagnosis

· Asthma (J 45.901)

· Congestive heart failure (150.20)

· Pneumothorax (J 93.9)

· Pleural effusion (J 90)

· Pulmonary embolism (126.99)

· Cardiac arrhythmia (149.9)

History of present illness

The patient has been experiencing short breathing for the last two years, and it has been getting worse for the past four days. The patient is positive for dyspnea on exertion. The patient has reported fever, chills, night sweats, chest pain, and palpitation. Moreover, the patient has signs of lower extremity edema. However, the patient was rather uncomfortable because of labored breathing. He has been using different kinds of inhalers, yet he has not completely recovered from the cough. He has been hospitalized multiple times for acute COPD exacerbations. The diagnosis is made based on present medical history, breathing profile, and spirometry results. FEV1/FVC ratio was 0.68 (68%). The ABG test indicated that the oxygen saturation is not satisfactory, the values are, PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86. The patient has a long history of smoking, and he is a chain smoker. He is not an alcoholic and does not use any illicit drugs. He needs urgent hospitalization for oxygen therapy.

Past medical history

· Hypertension (I10)

· Emphysema (J 43.9)

Past surgeries

· Hernia repair surgery (K 46.9)

· 2-day hospitalization

· Multiple hospitalizations for COPD

Family history

· Mother died of heart failure

· Father had COPD

· Brother has hypertension

· Sister is normal

Medication

· Lisinopril 20 mg BD

· Atorvastatin 20 mg BD

· Salmeterol 250/50 inhaler, two puffs daily

· Albuterol nebulizer every 8 hours daily

Hypertension

· Lotensin 40 mg OD

· Zestril 20 mg OD

Emphysema

· Duakril inhaler two puffs daily

Review of systems

Constitutional symptoms

Fatigue, 20 LB weight loss. Slight weakness, no fever, no night sweats.

The patient seemed fatigued, and he stated that he lost 20 LB weight during the last six months. However, the patient had no fever, and no sweating was observed.

Eyes

No obvious visual changes.

The color of the sclera was normal. Upon investigation, the patient said that he did not feel any visual problem. The diagnosis has no negative effect on ocular microvasculature. Retinal oxygen level is normal.

ENT

No epistaxis, no sinus pain, no odynophagia.

The patient denied any sort of nasal bleeding and sinus pain. The negative impact includes slight voice change sore throat due to persistent cough.

Cardiovascular

No edema, no palpitations, no chest pain.

The COPD exacerbation negatively impacts the heart rate. The heart rate increased slightly after some physical activity and the patient felt breathing problems.

Respiratory

Cough, sputum, wheezing, short breathing, exercise intolerance.

The patient indicated his major complaint as the presence of crucial symptoms such as persistent wheezing, change in color, and consistency of sputum.

Gastrointestinal

No abdominal pain, no indigestion, no bloating, slight nausea due to productive cough.

The patient indicated that he felt bloated right after a meal. The patient said that he felt slight nausea after coughing.

Genitourinary

No dysuria, hematuria, or polyuria.

No obvious genitourinary problems were observed. The patient mentioned that he had not any kind of difficulty in passing urine. Moreover, he did not indicate the presence of polyuria.

Musculoskeletal

No muscle pain, however, a slight decrease in the range of motion.

As the patient is 62 years old, he has slight disorientation and limited body motion. However, he did not indicate muscular pain. There is slight joint pain due to aging.

Integumentary

Cyanosis present on extremities.

Upon examination, there was slight cyanosis on the tips of fingers. Moreover, the color of the lips was also slightly blue.

Neurological

No headache, no seizures, no faints.

There were no neurological problems reported by the patient. The patient did not indicate blackout, headache, spasms, and convulsions.

Psychiatric

Slight anxiety due to breathing problems.

The patient presented no psychiatric problems. However, the patient was slightly nervous and uneasy due to breathing problems.

Objective

Vital signs

Temperature: 98.56, Heart Rate: 78, Blood Pressure:110/82, Respiratory Rate: 10, Weight, 58 kg, Height: 5ft 5 inches.

Physical examination

General

Slight weight loss due to stress-induced by labored breathing.

· Positives: anxiety, disturbed sleep pattern

· Negatives: confusion, fainting

The physical examination shows slight weight loss, pale skin, and cyanosis on the fingers. However, no lumps and bruises were present.

HEENT

No headache, normal sclera, intact oral mucosa, intact ear canal.

· Positives: sinus problem, nasal obstruction

· Negatives: eye pain, double vision

The head is atraumatic and normocephalic. Extraocular motility and alignment are normal. Slightly swollen neck arteries. There is no gingival bleeding. No oropharyngeal abnormalities were present.

Respiratory

Cough, wheezing,

· Positives: short breathing, exercise intolerance

· Negatives: hemoptysis, dry cough

The shape of the chest was slightly barreled. The wheezing and paradoxical abdominal movement was present. Moreover, there was an increased expiratory time.

Cardiovascular

No palpitations,

· Positives: short breathing, exercise intolerance

· Negatives: chest pain, oedema.

The patient was intolerant to physical exercise and breathing sound rather diminished. At the beginning of inspiration, coarse crackles were heard.

Gastrointestinal

No abdominal pain.

· Positives: nausea, loss of appetite

· Negatives: hematemesis, hematochezia

The belly was slightly swollen due to bloating and constipation.

Integumentary

· Positives: cyanosis, dry skin

· Negatives: pruritus, eczema

The skin was slightly dry, and there was cyanosis on the fingers and lips.

Extremities

· Positives: Slight clubbing, cyanosis

· Negatives: edema

Slight clubbing of fingers was present. Additionally, the patient said that he had cyanosis for the past three months.

Neurological

Normal body posture and no headache.

· Positives: anxiety, sleep patterns

· Negatives: fainting, special senses

The patient was active and conscious. However, he was slightly nervous due to breathing problems.

Lab investigations

1. ABG (82803)

PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86.

2. COPD assessment test (96417)

CAT score: 30

3. Sputum examination (87077)

o Yellow to brown color sputum

o Increased growth of Gram-negative and Moraxella catarrhalis

4. WBC (005025)

o 14000 cells/microliter

5. HB (85018)

14.1

6. Hematocrit (85014)

o 47 %

Imaging diagnostic tests

1. Spirometry (94010)

o FVC: 2.28 L

o FEV1: 1.56 L

o FEV1/FVC: 0.68

2. Chest X-Ray (71020)

o Dark pulmonary field

o The flattened diaphragm on the lateral view

o Increased air in the retrosternal area

o AP diameter increased

o Bullae present on both lungs

3. Ct scan (74178)

o Centrilobular emphysema

o Thick bronchial wall

o Small airway obstruction in both lungs

o Slightly narrow trachea at the coronal plane

o Pulmonary hypertension

Assessment

Acute diagnosis

Bronchiectasis (J 47.9)

This is an obstructive lung disorder that is often associated with a genetic cause. Bronchiectasis can occur alone or with COPD. However, the major difference is the age as Bronchiectasis occurs in early childhood.

Congestive heart failure (150.20)

The symptoms are related to COPD such as cough, wheezing, fatigue, and weakness. Short breathing is also a major symptom of congestive heart failure; therefore, it is often associated with COPD.

Tuberculosis (15.7)

TB is a highly contagious lung disorder with pertinent symptoms of weight loss, fatigue, persistent productive cough, short breathing. All these symptoms are closely related to COPD.

Chronic diagnosis

Asthma (J 45.901)

Asthma is one of the most common differential diagnosis of COPD. Both diseases have more or less the same symptoms. Long-term asthma results in COPD at later ages. Therefore, I prioritize asthma on my list of differential diagnoses.

Chronic bronchitis (J 42)

The disease's etiology is different from COPD; however, the symptoms are more or less the same. These include short breathing, wheezing with thick and increased mucus production.

Emphysema (J 43.9)

One of the major risk factors of COPD is emphysema. It is caused by long-term smoking or smoking from a very early age. The disease affects the alveolar sacs and damages them causing a severe type of cough and prolonged degeneration of the tissues (Ono et al., 2020).

Differential diagnosis eliminated

· Emphysema (J 43.9)

· Bronchiectasis (J 47.9)

· Chronic bronchitis (J 42)

Plan component

A treatment plan that corresponds with the diagnosis.

COPD needs effective treatment and management based on individualized assessment. Pharmacotherapy would be influential in reducing the symptoms and frequency of exacerbation.

Provide information on admission type

The patient must be admitted to a healthcare facility to receive medication therapy based on certain bronchodilators to curb the symptoms.

Types of diagnostics

All the pertinent diagnosis is performed, such as AGB, CAT, to assess airway obstruction severity.

Prescribed medications and dosages

Medication therapy

· Vibramycin 100 mg BD

· Levaquin 500 mg OD

· Long-acting bronchodilators beta2 agonist are preferred because the severity of obstruction is high (Gold C)

· Inhaled corticosteroid is the other treatment option for a patient with a severe form of COPD. The ICS also manages frequent exacerbation.

· Phosphodiesterase 4 inhibitors are also used in patients with COPD exacerbation with a long history of emphysema or chronic bronchitis.

· Individualized treatment is used in COPD exacerbation that is based on GOLD guidelines. Certain antibiotics are also added to secure treatment goals.

Oxygen therapy

· Long term oxygen therapy is used for COPD, and when the patient experiences severe hypoxia to improve his life expectancy, sleep, cognitive and physical performance.

· Pulmonary rehabilitation

· Noninvasive ventilation (Nunez et al., 2020)

Relevant consults or follow-up procedures needed

· Smoking cessation

· Assessment of symptoms control

· Reassessment of inhaler using technique

· Assessing the time for the need for referral

· Spirometry assessments

· ABG assessment

Ethical considerations

Ethical considerations are the principal ethics that allow the patient to make his decisions, autonomy, beneficence, and Non-Malfeasance

legal considerations

The healthcare system's legal consideration includes advance directives, confidentiality, and informed consent regarding his treatment.

Geriatric considerations

The geriatric patients are particularly more vulnerable to the adverse implications of the COPD acute exacerbation. COPD is generally a very common disorder in older patients; therefore, geriatric considerations are crucial in this context. Similarly, there is a high mortality and morbidity rate in older patients, and they cannot follow routine medical treatment. Appropriate care must be provided, including regular medication, proper use of an inhaler, nebulizers, physical exercise, and moral support.

References

Fermont, J. M., Bolton, C. E., Fisk, M., Mohan, D., Macnee, W., Cockcroft, J. R., ... & Wilkinson, I. B. (2020). Risk assessment for hospital admission in patients with COPD; a multi-centre UK prospective observational study. PloS one, 15(2), e0228940.

Nuñez, A., & Miravitlles, M. (2020). Preventing readmissions of COPD patients: more prospective studies are needed.

Ono, M., Kobayashi, S., Hanagama, M., Ishida, M., Sato, H., Makiguchi, T., & Yanai, M. (2020). Japanese patients' clinical characteristics with chronic obstructive pulmonary disease (COPD) with comorbid interstitial lung abnormalities: A cross-sectional study. PloS one, 15(11), e0239764.