SOAP

Clinical SOAP Assignment 2

Spring 2020 CPSC 3150

Background Information and HPI

Patient arrival- April 1, 2020 to a local level-1 trauma medical center

Chief complaint(s)- dry nonproductive cough, shortness of breath, general fatigue, loss of appetite, intermittent fever, rhinorrhea

Age and gender- 45-year-old male, Caucasian

Smoking history- never been a smoker

Pulmonary history- no diagnosed lung disease

Height and weight- 5 foot 10 inches, 175 lbs.

Work history- assistant manager at a local grocery store

Home therapy- no home oxygen, Metformin, lisinopril, and atorvastatin

Comorbidities- diabetes, hypertension, and hypertriglyceridemia

Subjective Information

Upon patient interview, the patient disclosed the following:

· Signs and symptoms of illness began four days prior to seeking medical care

· Began as relatively mild but seems to be getting worse

· Cough is strong and frequent but nonproductive

· Feels like he cannot “catch his breath”

· Has not felt like doing much and called in sick to work yesterday

· Some nausea leading to loss of appetite

· Treating low grade fever with Tylenol as needed

· Nasal secretions are clear and watery, patient associates with seasonal allergies

· Patient denies any chest pain

· Has not been wearing a mask to work

Providers perform a thorough physical examination and diagnostic testing.

Objective Information

Physical assessment- patient was alert to person, place, and time; no cyanosis or clubbing noted; no pitting edema present; normal body habitus; no signs of respiratory distress. Inspection, palpation, and percussion revealed no chest abnormalities.

Initial vital signs- BP 135/88, HR 110, RR 16, Temperature 99.5 F, Sp02 95% on RA

ECG- sinus tachycardia

CXR- Initial image on 4/1 demonstrated no acute changes

Bilateral breath sounds- rhonchi was heard bilaterally

ABG- pH 7.39, PaC02 42 mmHg, Pa02 80 mmHg, HC03 24, BE 0 on room air 4/1

Laboratory data- CBC, electrolytes, coagulation testing, liver and renal function panel, C-reactive protein level, and lactate was obtained. The following were considered abnormal:

· Lymphocytes 750/microliter

· Platelets 100,000/microliter

· C-reactive protein 3 mg/L

· Lactate 1.5 mmol/L

The patient was screened for influenza type A and B- both were negative.

The patient was also swabbed for Covid-19 due to potential community exposure with a real time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay (nasal and pharyngeal). The patient was admitted for observation until the results of the assay were confirmed/ruled out and placed in droplet/airborne/contact isolation as a precaution.

The next day the results of the rRT-PCR confirmed the presence of Covid-19 infection. The patient remained stable until repeat examination and diagnostic testing on 4/7 revealed:

Vital signs- BP 140/90, HR 120, RR 28, Sp02 90% on RA

Bilateral breath sounds- crackles/rales heard in both lung bases

ABG- pH 7.35, PaC02 44 mmHg, Pa02 60 mmHg, HC03 22, BE -2 on room air

CXR- bilateral patchy opacities indicative of atypical pneumonia

Physician’s Plan

The patient was placed on supplemental oxygen at 2 liters/min via nasal cannula. The following medications were given while admitted to the hospital:

· Vancomycin

· Cefepime

· Remdesivir

· Guaifenesin

· Acetaminophen

· Intravenous normal saline

Continue to isolate the patient and monitor symptoms of Covid-19. Report incidence to CDC and local health department.

Assessment and Plan

Based on the information provider, the student will follow the SOAP guidelines and complete a narrative report of this case. Remember to research and provide an interpretation for any abnormalities, comorbidities, and medications. Please use this opportunity to learn more about an emerging virus that you may be tasked with treating in the future. Though we do not know much, there is some evidence that will help support your understanding of the disorder and provide guidance on the best treatment options. Please include a description of when the clinical manifestations turn severe and how the provider may then incorporate more critical care strategies (mechanical ventilation). Also, incorporate the role and importance of your clinical competencies from this semester whenever appropriate (which ones are indicated, contraindicated, etc.?).