Draft 2

10

Academic Clinical SOAP Note

MUHAMMAD AFTKHAR

GRAND CANYON UNIVERSITY

5/22/2021

Academic Clinical SOAP Note

Subjective

Chief complaint

The woman presented to the hospital with a chief complaint of shortness of breath (Sharma et al., 2020).

Primary working diagnosis

· Histoplasmosis (B39.9)

Severe shortness of breath with abnormal respiratory rate. Normally, a person has 12-20 breaths in one minute. But she has more than 20 breaths in a minute. This condition is tachypnea.

Pending differential diagnosis

· Bacterial pneumonia (J15.9)

· Immunodeficiency state and Pneumocystis jirovecii pneumonia (B59)

· Carcinoid lung tumors (C7A. 090)

· Tuberculosis (86580)

· Chlamydial pneumonia (138338)

· Mediastinal cysts (39401)

· Recurrent mycoplasma infection (A49.3)

· Pancoast syndrome (C34.1)

· Pneumococcal infection (J18.9)

· Aspergillosis (B44.9)

· Blastomycosis (B40.9)

· Actinomycosis (A42)

History of present illness

A 33-years-old Caucasian woman is admitted to the general ward of the hospital. She was brought to the hospital with a chief complaint of a breathing problem. She notified that she had experienced shortness of breath about six months back. A primary care practitioner diagnosed her with bronchitis at that time and prescribed her bronchodilators along with initiation of empirical antibiotic therapy and oral intake of steroids as well. Moreover, she said this prescription is strictly followed but does nothing to improve my condition. In six months, the condition has become worse than before (Sharma et al., 2020).

Past Medical history:

· Hypertension (99473)

Family history:

· Father has hypertension

· Mother is normal

· Siblings are normal

Past Surgical History:

· Cholecystectomy (47563)

Social History:

The female is working in a bakery shop as a worker. She is married and has three children. His elder child is five years old. She has no hobbies like playing golf. She used to travel to Mexico once a year. She reports cigarette smoking for a long time. But she reduces the consumption of tobacco after the occurrence of symptoms, i.e., from the previous six months. She refuses the use of alcohol or any illegal drugs.

Reproductive History:

She delivered her third baby 15 months ago. She has sexual relations with his husband only and denies any illegal sexual relations with others.

Current Medications

· Anti-hypertensive Drug:

A 10 mg oral dose of Lisinopril

· Budesonide 0.5mg/ 2ml nebulizer 0.25mg, twice daily

· Levofloxacin 750 mg IV q24h

· Ipratropium-Albuterol 0.5-2.5 mg/3ml, Q4h, PRN

Allergies/Adverse Effects:

No significant food, drug, or environmental allergy/adverse reaction is reported.

Review of System (ROS)

· General: The body vitals are normal. The body temperature is 98.9, with no chills and fatigue.

· HEENT: The vision is normal. No blurred vision is observed.

· Skin: No skin allergies and burns are reported.

· Genitourinary: The colour and odour of urine are normal. No bladder intolerance.

· Neurological: Never experience migraine, paralysis, seizures, ataxia, shocks, or hallucination.

· Lymphatic: The lymph tissues are normal and functioning properly.

· Endocrine: The endocrine system is normal.

· Cardiovascular: The blood pressure and heart rate are normal (88). No arrhythmia with murmur sound, rubs, and gallops are reported.

· Respiratory: Mild cough, tachypnea, and diffused rales are reported.

· Gastrointestinal: She has normal bowel sounds X4 without any gastrointestinal tract problems like diarrhea, constipation, bruits, or anorexia.

· Musculoskeletal: No muscular or bone weakness.

· Hematologic: No bleeding disorders, pancytopenia.

Objective

Physical Exam

Vital Signs:

T: 97.8 degrees F; HR: 88; RR: 22; BP: 130/86; BMI: 28 (over-weight).

General:

She is normal and conscious in appearance. She has severe shortness of breath but lying satisfied on the hospital bed and talking to everyone pleasantly. The respiratory distress does not allow her to complete her sentence. However, she was slightly anxious because of abnormal breathing patterns.

Cardiovascular:

No palpitations, rubs, or gallops,

· Positives: Shortness of breath

· Negatives: Chest congestion, rapid heart rate

The blood pressure and heart rate are normal (88). She has a normal heart rhythm without murmur sound.

Respiratory:

Wheezing and diffused rales,

· Positives: Tachypnea, dyspnea

· Negatives: Hemoptysis, Flu-like symptoms

There was shortness of breath, especially on excretion.

Gastrointestinal:

Normal bowel sounds X4

· Positives: Increase intestinal activity, bloating

· Negatives: Bruits, diarrhea, or pulsatile mass.

Bloating increases intestinal activity and has produced abdominal sounds X4.

Neurological:

The patient appearance and behavior are normal.

· Positives: anxiety, sleep patterns

· Negatives: loss of consciousness, headache

Hematological:

No bleeding disorder is reported,

· Positives: Pancytopenia

· Negatives: Anemia

The CBC reports show a 74,000 mm3 Hg platelet count.

Laboratory Initial investigations:

CBC (85027)

Relatively low WBCs, RBC, and platelets (74,000) (Pancytopenia)

AST (84450)

Increased serum levels AST= 90

ALT (84460)

Increased serum levels ALT= 112

Blood Culture (87040)

No bacterial infection with gram staining.

Chest X-ray (71010)

Increase lungs density

Imaging Test

CT scan (74178):

Disseminated centrilobular micronodular appearance having no pivotal consolidation, but pulmonary consolidation is present.

Cytological Examination

Bronchoscopy (31622):

The bronchoscopy allows us to assess either the consolidation is due to a malignancy or an infection. The cloudy and muddy discharge in bronchoscopy is analyzed, which confirms the presence of Histoplasma capsulatum. This fungus causes pulmonary histoplasmosis. The patient is diagnosed with pulmonary histoplasmosis. She has immuno-competency to fight against this fungus.

Assessment

Acute Diagnosis

Carcinoid lung tumors (C7A. 090):

Carcinoid lung cancer is often confused with histoplasmosis. The patient has a history of tobacco smoking, so it might be possible that the clinical symptoms are due to carcinoid lung cancer.

Sarcoidosis (D86.0):

Sarcoidosis mimics almost all symptoms of histoplasmosis. It is mistakenly taken as histoplasmosis several times. Both diseases can be differentiated by cytological investigation.

Chronic Diagnosis

Mild Interstitial Pneumonitis (J84.10):

Pulmonary consolidation (pus-filled in air sacs affecting the lung density) misdiagnosed the mild interstitial pneumonitis. The patient's condition is the same in pneumonia as in histoplasmosis.

Small Cell Lung Cancer (34.90):

Many histoplasmosis patients reported who were misdiagnosed with neck the neck or lung cancer. Malignancy is similar to consolidation. So, it does not allow an accurate diagnosis.

Differential Diagnosis Eliminated

Bacterial Pneumonia (J15.9):

Shortness of breath is the common feature of pulmonary diseases. The blood culture shows no bacterial infection; that's why this differential diagnosis is eliminated.

Components of Plan

A Treatment Plan That Corresponds with the Diagnosis

In most cases, histoplasmosis is asymptomatic, but sometimes it presents symptoms. The patient was not getting better with empirical antibiotics and bronchodilators. Pancytopenia in laboratory studies shows the immune system is affected. Furthermore, pulmonary consolidation in the scan evidence there is an infection or a tumor in the lung. I've initiated broad-spectrum antibiotic therapy. But therapy does not work. That's why anti-fungal therapy is initiated for efficacious management.

Oxygen: 2L Oxygen Via N/C when O2 is below 92%

Diet: Pt Will continue regular diet

Deep Venous Thrombosis Prophylaxis: Pt will use continuous compression stocking in bed.

Provide Information on Admission Type

The patient is required to be admitted to a medical ward of the hospital until her breathing rate is optimized (12-20 breaths per minute).

Types of Diagnostics

All the pertinent diagnosis is performed, such as blood tests, bronchoscopy, and CT scan to assess the extent of pulmonary consolidation.

Prescribed Medications and Dosages

Medication therapy

· Itraconazole is an anti-fungal pharmaceutical. It is used to fight histoplasmosis.

· A dose of 200 mg twice a day for 1-2 years will allow successful management.

· A total of 24 mg methylprednisolone is given in divided doses for bronchial inflammation. This will improve shortness of breath.

· The incidence of bacterial infection is frequent in histoplasmosis. If symptoms persist, then antibiotic therapy will be initiated within 2-4 months.

Relevant Consults or Follow-up Procedures Needed

· Pancytopenia assessment

· Efficacy assessment of selected anti-fungal (otherwise switched with amphotericin B)(Pincelli et al., 2019)

· Optimization of tachypnea

· If associated complications are overcome with the initiation of anti-fungal agents, the patient's discharge is planned.

· But she is directed for follow-up visits

Ethical Consideration

The patient had this infection for the past six months, but the misdiagnosis of her primary physician adds up to her complications. It could be fatal (Cano-Torres et al., 2019). The key point to consider is not all CT scans or chest X-ray only report for pneumonia.

Legal Consideration

It is the responsibility of every physician to overlook the outcomes of a particular treatment intervention. If the patient's condition is not improving, it means either the disease is misdiagnosed, or the treatment therapy is not appropriate.

Geriatric Consideration

The geriatric population loses immunocompetency as age advances. They are more vulnerable to infections. They should maintain an immune-boosting diet along with proper hygiene in their lifestyle. They are suggested to avoid pets like doves. The present patient has two male dove pets that might be the cause of this infection.

References

Sharma, S. Hashmi, M. F. & Rawat, D. (2020). Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. NCBI Bookshelves, https://www.ncbi.nlm.nih.gov/books/NBK500024/#_article-41348_s9_

Cano-Torres, J. O., Olmedo-Reneaum, A., Esquivel-Sánchez, J. M., Camiro-Zuñiga, A., Pérez-Carrisoza, A., Madrigal-Iberri, C., . . . Belaunzarán-Zamudio, P. F. (2019). Progressive disseminated histoplasmosis in Latin America and the Caribbean in people receiving highly active antiretroviral therapy for HIV infection: A systematic review. Med Mycol, 57(7), 791-799. doi:10.1093/mmy/myy143

Pincelli, T., Enzler, M., Davis, M., Tande, A. J., Comfere, N., & Bruce, A. (2019). Oropharyngeal histoplasmosis: a report of 10 cases. Clin Exp Dermatol, 44(5), e181-e188. doi:10.1111/ced.13927