Benchmark clinical soap note

Running head: BENCHMARK: ACADEMIC CLINICAL SOAP NOTE 1

Benchmark Academic Clinical Soap Note

Grand Canyon University

ANP 652

February 05, 2020

Admission Date: 12-03-2019

Chief Complaint:

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2 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Patient c/o worsening SOB since this morning.

Background:

This is a pleasant 33-year-old obesity Hispanic male who presents to emergency room

and does not go and see any doctor, comes in with some shortness of breath and cough. Pa-

tient notes that he has been having shortness of breath with productive cough for a few days.

Patient states his wife also notes he has been wheezy however denies any history of COPD,

asthma or smoking. Patient does note he works in construction and dry wall however does

use respirator. Nothing has made symptoms better. Symptoms were worse after walking and

shower at home. No eliciting factors have been noted. Symptoms are moderate to severe. Pa-

tient does have some productive sputum and intermittent wheezing. Denies any history of

COPD, asthma, similar illness. Denies any smoking. Denies any hemoptysis. Patient does

note he works in construction and dry wall however does use respirator.

Hospital Medications:

❖ acetaminophen, 650 mg= 2 TAB, PO, Q4H (Every 4 hours), PRN

❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, TID (3 times a day)

❖ Albuterol NEB, 2.5 mg= 3 mL, NEB, Q2H (Every 2 hours), PRN

❖ cefTRIAXone 2 g IV Push, Q24 (Every 24 hours)

❖ montelukast, 10 mg= 1 TAB, PO, QHS (At bedtime)

❖ nitroglycerin, 0.4 mg= 1 TAB, Sublingual, 5MX3 (Every 5 minutes x 3 doses), PRN

❖ ondansetron, 4 mg= 2 mL, IV Push, Q4H (Every 4 hours), PRN

❖ Saline Flush, 10 mL, IV Push, Q12H (Every 12 hours)

❖ Zithromax, 500 mg= 2 TAB, PO, Q24H (Every 24 hours) Review of Systems:

Constitutional: No fever, no chills, no sweats, no weakness.

Eye: No recent visual problem, icterus, discharge, blurring, double vision.

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Ear/Nose/Mouth/Throat: No decreased hearing, ear pain, nasal congestion, sore throat.

Respiratory: Dyspnea, + wheezing.

Cardiovascular: Chest pain with coughing.

Gastrointestinal: Denies nausea or vomiting

Genitourinary: No dysuria, hematuria, or pain.

Hematological/Lymphatics: No bleeding tendency, swollen lymph glands

Endocrine: No excessive thirst, polyuria, cold intolerance, heat intolerance, excessive

hunger.

Immunologic: No recurrent fevers, recurrent infections, malaise

Musculoskeletal: No back pain or trauma.

Integumentary: No Rash, pruritus, abrasions, breakdown, burns, petechiae, skin lesion.

Neurologic: No headache, dizziness, numbness, weakness. Alert and oriented X4.

Psychiatric: No sleeping problems, irritability, or mood swings/depression.

All other systems are negative

Vital Signs:

T: 98.7 F TMIN: 98.7 F TMAX: 98.9 F HR: 126 RR: 22 BP: 167/77 SpO2:

96% WT: 105 kg BMI: 36.33

Physical Examination:

General: Well nourished, alert, cooperative, moderate discomfort.

HEENT: Normocephalic, oral mucosa is moist, normal sclera, no JVD.

Respiratory: Mild wheezes bilaterally, prolonged expiration , respirations non-labored. Car-

diovascular: Tachycardic, borderline hypoxemia

Gastrointestinal: Soft, no guarding, present bowel sounds, no tenderness.

Integumentary: Warm, no rash, skin turgor not decreased.

Musculoskeletal: Normal range of motion, no deformity.

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4 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Neurologic: CN2-12 intact. No focal deficits. Fluent speech. Alert, Oriented x 4.

Psychiatric: Cooperative, appropriate mood & affect.

Abnormal Labs/Imaging/ Diagnostic Test Result: 12/03/2019

❖ WBC 15.9 (High)

❖ Neutrophils 70 % (High)

❖ Lymphs 19 % (Low)

❖ Neutro Absolute 11.08 (High)

❖ Lymph Absolute 3.02 (High)

❖ Mono Absolute 1.13 (High)

❖ Eos Absolute 0.54 (High)

❖ Basophil Absolute 0.06 (High)

❖ Glucose 134 (High)

❖ Albumin Level 5.1 (High)

❖ Total Protein 8.9 (High)

❖ AST 56 (High)

❖ ALT(SGPT) 86 (High)

Influenza B PCR NEGATIVE

Influenza A PCR NEGATIVE

Diagnostic Data: CT Chest: CT Angio chest negative for PE, there is bilateral infiltrates present, likely pneumo-

nia. Prominent mediastinal lymph nodes likely infectious or inflammatory.

Diagnostic Data: EKG:

Sinus tachycardia 131 beats per minute. No ST segment elevation or depression, no

STEMI.

ASSESSMENT/CLINICAL IMPRESSIONS

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5 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Health Problems:

1. SOB R10.9

2. Community Acquired Pneumonia J18.9

3. Leukocytosis D72.829

Differential Diagnosis:

ICD-10 J45.51: Asthma Exacerbation- is an acute or subacute episode of progres-

sive worsening of symptoms of asthma, including shortness of breath, wheezing, cough, and

chest tightness. Exacerbations are marked by decreases from baseline in objective measures

of pulmonary function, such as peak expiratory flow rate and FEV1 (Epocrate. 2019).

PLAN COMPONENT MANAGEMENT:

Patients with community-acquired pneumonia often present with cough, fever, chills,

fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected

community-acquired pneumonia, the physician should first assess the need for hospitalization

using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clini-

cal judgment (Lutfiyya, Henley, Chang, & Reyburn, 2006). When initially diagnosing and

treating community acquired pneumonia (CAP) the patients’ laboratory results, physical ex-

amination findings, and patients’ characteristics description (e.g., age, smoking history,

chronic illnesses) will play an important role. Physicians should begin their treatment deci-

sions by assessing the need for hospitalization using a prediction tool for increased mortality,

such as the Pneumonia Severity combined with clinical judgment (Lutfiyya, Henley, Chang,

& Reyburn, 2006). In this patients case the plan included the admission to a medical floor

which included continuous tele-monitoring, overnight stay of 2 days or more, will follow pa-

tients procalcitonin level making to prevent level for increasing possibly leading to sepsis, or-

dered CT Angio chest and chest x-ray, continue albuterol treatment as need for shortness of

breath, continue IV steroids, and empiric antibiotic coverage, deescalate per course. This pa-

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tient is considered a low risk patient and could have been treated at home but an admission

into the hospital was recommended in this case because based on this patient’s current habits

we felt that he pose a higher risk of complication and he would more likely to benefit from

hospitalization interventions (FitzGerald & Gibson, 2006).

Disposition/ Discharge Plan:

Once a patient with CAP is hospitalized, further management will be dictated by the

patient's response to initial empiric therapy (Ramirez, 2019). Clinical response should be as-

sessed during daily rounds. While various criteria have been proposed to assess clinical re-

sponse, we generally look for subjective improvement in cough, sputum production, dyspnea,

and chest pain (Ramirez, 2019). Objectively, we assess for resolution of fever and normaliza-

tion of heart rate, respiratory rate, oxygenation, and white blood cell count. Generally, pa-

tients demonstrate some clinical improvement within 48 to 72 hours. Hospital discharge is

appropriate when the patient is clinically stable, can take oral medication, has no other active

medical problems, and has a safe environment for continued care (Ramirez, 2019). Patients

do not need to be kept overnight for observation following the switch to oral therapy. Early

discharge based on clinical stability and criteria for switching to oral therapy is encouraged to

reduce the risk associated with prolonged hospital stays and unnecessary costs (Ramirez,

2019). Although the majority of patients diagnosed with community acquired pneumonia re-

cover without complications the elderly population continues to exhibit a significantly higher

mortality rate than the younger population. In this patient’s case, he stayed in the hospital for

a full three days and he was able to return home and manage his care at home.

Health Education/ Promotion and Disease Prevention:

To prevent community acquired pneumonia the first steps will be to stop smoking if

the patient is a smoker, then the focus is on receiving influenza and pneumococcal vaccina-

tions (Kaysin & Viera, 2016). This patient’s underline condition was asthma. With CAP the

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7 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

patient with asthma must get their asthma under control and once this patient is under the care

of a practitioner for asthma management he should stay active to help the lungs fight off in-

fection for future prevention. Other helpful tips are to wash hand with soap and water often,

make sure surfaces in the household is cleaned often, always cover your mouth when cough-

ing, try to avoid people who have a cold or the flu, taking and completing medication as di-

rected by the provider is very important, and drinking plenty of fluids and getting the proper

amount of rest helps the body heal. A healthy young person may lead a normal life within a

week of recovery from pneumonia. For others, however, weeks may go by before they get

back their usual strength and feeling of well-being. They should not be discouraged from re-

turning to work or carrying out their usual activities, but they should be warned to expect

some difficulties. Most important patients with CAP will start to feel better in 48 to 72 hours

but while at home if the patient t continues a fever after 72 hours, if there is a return of short-

ness of breath, patient notice a change in sputum color from clear to rust/ green, or the patient

just does feel better then he/ she needs to return to the emergency room.

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8 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

References

Acute asthma exacerbation in adults. (2019, December). Retrieved from https://online.e-

pocrates.com/diseases/4531/Acute-asthma-exacerbation-in-adults/Diagnostic-Ap-

proach

FitzGerald, J. M., & Gibson, P. G. (2006, November). Asthma exacerbations: Prevention. Re-

trieved from https://www.ncbi.nlm.nih.gov/pubmed/17071835

Kaysin, A., & Viera, A. J. (2016, November 1). Community-Acquired Pneumonia in Adults:

Diagnosis and Management. Retrieved from

https://www.aafp.org/afp/2016/1101/p698.html

Lutfiyya, M. N., Henley, E., Chang, L. F., & Reyburn, S. W. (2006, February 1). Diagnosis

and Treatment of Community-Acquired Pneumonia. Retrieved from https://www.aaf-

p.org/afp/2006/0201/p442.html

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9 BENCHMARK: ACADEMIC CLINICAL SOAP NOTE

Ramirez, J. O. (2019, November 11). Overview of community-acquired pneumonia in adults.

Retrieved from https://www.uptodate.com/contents/overview-of-community-ac-

quired-pneumonia-in-adults#H2940551536

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