Soap note

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:L.G

Age: 74

Gender at Birth:

Gender Identity: Female

Source:

Allergies:

Current Medications:

1-Aspirin 81 mg daily.

2-Lisinopril 20 mg daily

3- atorvastatin 20 mg daily,

4-fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day

5-ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed;

6- levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.

Denies the use of herbal supplements.

PMH: Patient had significant medical history for COPD,HTN, Hearing loss

Allergies: NKDA.     

Immunizations: Childhood immunizations are up to date.

Preventive Care:

Surgical History:

Family History:

Mother: 94 years old, Alive – Anxiety, GERD, CAD, Asthma

Father: Deceased - coronary artery disease (CAD) < 55 years,

Brother: Alive – HTN, DM type II, COPD (76 years old)

Son: Alive - no known health concerns (50 years old).

Social History: Currently married with one child who lives with them, they live in a single home that owned She is Christian. She every day works in the garden early in the morning, but lately is difficult to this due to increases the shortness of breath. Admitted that she smokes and she tries to cut but it is difficult, but she is the thing to quit (no guns in the home, no lead exposure)

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint: “Shortness of breath.”

Symptom analysis/HPI:

The patient is … is a 74-year-old female who presents today to the clinic, complaint worsening of the shortness of breath, wheezing and increases productive cough with no changes in the sputum color. She has experiences with dyspnea in exertion, she did not report fever, night sweet or chest pain or palpitation. She had had a history of chronic obstructive pulmonary disease (COPD) exacerbation twice last year, hypertension (HTN), and cardiac Cath about 3 years ago. She had a 40 pack-year smoking history but did not report using alcohol or illicit drug. Her medication, low dose daily (81mg) aspirin (ASA), Lisinopril 20 mg daily, atorvastatin 20 mg daily, fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day tiotropium inhaler 18 mcg 1 cap daily, ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed; and levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL Positive for fatigue, exhaustion, and lack of energy. Negative for fever, chills, malaise, night sweats, and anorexia

NEUROLOGIC: Negative for difficulty with concentration, poor balance or falls, slurred speech, headaches, numbness, or vertigo

HEENT:

Eyes: Admit her last eye exam was 3 years ago. She uses glasses all the time for vision. Denies any redness drainage or itching.

Ears: Positive for hearing the loss in the left ear corrected with hearing aids. Denies discharge, ear pain, or tinnitus.

Nose/Mouth/Throat: Negative for difficulty swallowing, hoarseness, gum diseases, and sore throat, have a superior prosthesis, inferior natural teeth.

RESPIRATORY: Positive for shortness of breath, cough, wheezing, and dyspnea on exertion that has been worse over the last couple of months and increasing exercise intolerance; denies hemoptysis or orthopnea; reports that even with the use of neb every 3-4 hours is still finding it hard to breathe well.

Breast: Deferred

CARDIOVASCULAR: Denies chest pain or palpitation

GASTROINTESTINAL: Negative for abdominal pain, nausea, vomiting, dysphagia, diarrhea, black or tarry stools, or blood in stools.

GENITOURINARY: Denies burning sensation during urination, lower abdominal pain, blood in the urine or vaginal discharge.

Last Pap Smear: 09/2020

Menarche: 11 years Menopause:52 years’ old G1P1A0

MUSCULOSKELETAL: Denies any complications with a range of motion in all four extremities, stiffness fracture as well as injuries or trauma to his head.

SKIN: Warm and dry, no rashes bruising or bleeding Exposed skin is intact. Various scattered solar lentigines. Denies any rashes, lacerations, or wounds.

PSYCHIATRIC:

Negative for anxiety, depression and suicidal ideation. Positive for sleeping disturbed.

Objective Data:

VITAL SIGNS: Weight:  196 BMI:24.5 Temp: 97.3 BP: 130/78 Height: 6.3

Pulse: 70 Resp: 20

GENERAL APPREARANCE: This 74-year-old female, ill appearance with some audible wheezing present and rapid breathing while sitting in a chair, makes eyes contact and answer the question appropriately. Well, grooming nourishment and hydrates. Dresses appropriately and cooperative with the examination

NEUROLOGIC:

HEENT: Head is normocephalic, no facial tenderness over frontal sinuses with palpation. Conjunctiva pink, sclera white without jaundice. PERRLA. Ears: External auditory canals mild cerumen. Tympanic membranes are intact. Nasal mucosa moist without drainage, septum midline. Oropharynx pink and moist with no tonsillar enlargement, lesions or exudate. Teeth superior prosthesis in place and intact. Mucus membranes are moist. Neck: Trachea is midline, thyroid not palpable. No JVD. No lymph nodes are palpable. Neck no supple with no masses or tenderness.

CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 normal. No S3, S4, rubs, murmurs, clicks, snaps, or gallops noted. Peripheral Vascular: No cyanosis, clubbing, or edema. Radial pulses 3+ bilaterally

RESPIRATORY: Symmetric chest walls with decreased expansion, deformity -shaped chest. Respiration even and labored, depth normal. Lung resonant. No fremitus. Decreased breath sounds in right upper lobe (RUL) and wheezes on left, most pronounced in posterior left lower lobe (LLL) and anterior left upper lobe (LUL). Able to talk in full sentences but appears short of breath when he finishes.

GASTROINTESTINAL: Abdomen soft and depressible, non-tender, bowel sounds of normal quality in all four quadrants. No hepatosplenomegaly

GENITOURINARY: Deferred

BREAST: Deferred

MUSKULOSKELETAL: Steady gate, no limping or musculoskeletal deformities. No swelling, joint pain, crepitus, warmth or tenderness. Full ROM. Limited movement due to back pain

INTEGUMENTARY: Intact. No ulcers. Nails without clubbing or cyanosis at this time. No petechiae or ecchymosis. Various scattered solar lentigines

NEUROLOGICAL:

CNII-XII intact, Posture erects, steady gait. Speech clear.

PSYCHIATRIC: A&O&4 Pt. dressed in clean season appropriate clothes.

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

The patient is … is a 74-year-old female who presents today to the clinic, complaint worsening of the shortness of breath, wheezing and increases productive cough with no changes in the sputum color. She has experiences with dyspnea in exertion, she did not report fever, night sweet or chest pain or palpitation. She had had a history of chronic obstructive pulmonary disease (COPD) exacerbation twice last year, hypertension (HTN), and cardiac Cath about 3 years ago. She had a 40 pack-year smoking history but did not report using alcohol or illicit drug. Her medication, low dose daily (81mg) aspirin (ASA), Lisinopril 20 mg daily, atorvastatin 20 mg daily, fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day tiotropium inhaler 18 mcg 1 cap daily, ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed; and levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.

on examination I noted Regular rate and rhythm. S1 and S2 normal. No S3, S4, rubs, murmurs, clicks, snaps, or gallops noted. Peripheral Vascular: No cyanosis, clubbing, or edema. Radial pulses 3+ bilaterally .Symmetric chest walls with decreased expansion, deformity -shaped chest. Respiration even and labored, depth normal. Lung resonant. No fremitus. Decreased breath sounds in right upper lobe (RUL) and wheezes on left, most pronounced in posterior left lower lobe (LLL) and anterior left upper lobe (LUL). Able to talk in full sentences but appears short of breath when he finishes.

Main Diagnosis

Chronic obstructive pulmonary disease with (acute) exacerbation (J44.1): Chronic Obstructive Pulmonary Disease, or COPD, refers to a group of diseases that cause blockage of the air passage. They include emphysema, bronchitis chronic and, in some cases, asthma. The common signs and symptoms of COPD are: cough persistent, or that produces a lot of mucus; This cough is often referred to as "smoker's cough" feeling of shortness of breath, especially during physical activity wheezing or a whistle or squeak that occurs when you breathe pressure in the chest. The intensity of the symptoms will depend on the degree of lung damage. Severe COPD can cause other symptoms, such as swelling of the ankles, feet or legs, weight loss and decreased muscle capacity (Goolsby & Grubbs, 2014).

Differential diagnosis (minimum 3)

- Heart failure (I50.9): Heart failure is usually a slow process that gets worse over time. The symptoms allow determining which side of the heart does not work properly. If the left side of the heart does not work well (left heart failure), blood and mucus build up in the lungs. The patient easily loses his breath, feels very tired and has a cough (especially at night). In some cases, patients expel bloody sputum when coughing. If the right side of the heart does not work well (right heart failure), fluid builds up in the veins because the blood circulates more slowly. The feet, legs, and ankles begin to swell. This swelling is called "edema." Sometimes the edema can spread to the lungs, liver, and stomach. Due to the accumulation of fluid, the patient has a need to urinate more frequently, especially at night. The accumulation of fluid also affects the kidneys, reducing their ability to remove salt (sodium) and water, which can lead to kidney failure (Domino, Baldor, Golding, & Stephen, 2017).

Chronic obstructive asthma (J44.9): Asthma affects people of all ages, but usually begins during childhood. In the United States, there are more than 25 million people with proven asthma. Of these people, about 7 million are children. Asthma is a chronic disease of the lungs that inflames and narrows the airways. Both asthma and COPD may cause shortness of breath and a cough. A daily morning cough that produces yellowish phlegm is characteristic of COPD. Episodes of wheezing and cough at night are more common with asthma. Other symptoms of COPD include fatigue and frequent respiratory infections (Domino et al., 2017).

Bronchogenic Carcinoma C34.90): Bronchogenic carcinoma (CB) is the most frequent neoplasm and the main cause of cancer death in the male Its incidence is increasing in the female sex. The most common symptoms of lung cancer are: A cough that does not go away or gets worse, cough with blood or sputum (saliva or phlegm) of the color of oxidized metal , chest pain that often gets worse when you take a deep breath, cough or laugh, hoarseness, weight loss and loss of appetite difficulty breathing ,tiredness or weakness, infections such as bronchitis and pneumonia that do not disappear or continue to recur, new chest whistle, (Domino, et al., 2017).

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

Lab Test: (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017).

CBC with differential pending

CMP pending

Special Test:

Chest X-ray: Ordered for visualization of lungs due to decreased breath sounds in the right upper lobe. With smoking history and increased shortness of breath, there is a concern for lung cancer.

-

Pharmacological treatment: (Buttaro et al., 2017).

Short-Acting

Ipratropium bromide, Solution for nebulization, 500 µg/2.5 mL 3-4 times per day, separate doses by 6-8 hr.

Long-Acting:

Tiotropium DPI, 18 µg/inhalation 1 inhalation daily

Beta2-adrenergic agonists

Albuterol sulfate, Solution for nebulization, 0.5 mL of 0.5% solution, 3-4 times per day

Oral corticosteroids

Methylprednisolone 40-48 mg/day in divided doses for 3-4 days.

Non-Pharmacologic treatment:

Patients was educated on COPD including the signs and symptoms, course of exacerbations

. The use of inhalers was demonstrated to the patient

Patient was educated on the importance of risk reduction including the importance of smoking cessation

The importance of Influenza and pneumococcal vaccination was discussed with the patient. The importance of the vaccination was discussed in relation to reduce risk of exacerbations

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

Referral to Pulmonary Rehabilitation: Respiratory therapist to facilitate breathing techniques and guidance for maximizing energy, which has improved both patients' exercise tolerance and symptoms of dyspnea and fatigue.

Referral to dietitian-nutritionist: In order to instruct the patient on nutrition, exercise, upper body weight training, and eat frequent, small meals instead of a large meal; large meals cause abdominal distention, which impairs diaphragmatic function

Psychological Support: Patient may feel anxious, depressed, and fatigued. Counseling is recommended for those patients exhibiting signs and symptoms of major depression

Follow up in 72 hours and as needed if symptom no improves patient can go to the ER

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

References

Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed). St. Louis, MO: Elsevier

Domino, F, J., Baldor, R. A Golding, J &, Stephen, M (2017). The 5-minute Clinical consult (25thed). Philadelphia, PA: Wolters Kluwer

Goolsby, M. J. & Grubbs, L. (2014). Advanced assessment: Interpreting findings and formulating differential diagnoses, (3rd ed.). Philadelphia, PA: F. A. Davis. ISBN: 9780803643635

ICD10. (2018). Retrieved from https://www.icd10data.com/search

Kennedy-Malone, L., Fletcher, k. R., & Martin-Plank, L. (2014). Advanced Practice Nursing in the Care of Older Adults, (1st ed.). F. A. Davis Company. ISBN: 9780803624917