case study

Week 7 Soap Note

Submit a correctly formatted SOAP note on the identified patient.

Titile: “Adult Female with Amenorhea” (Women’s Health)

Example: 26-year-old female presents to the clinic with complaints of not having a menstrual period for 4months

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Student name

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Course name

Professors name

Due date

Adult Pulmonary (COPD)

ID: J.T., DOB: 03/25/1956, Age: 69, African American male presents to the clinic accompanied by his wife, and he is a reliable historian

SUBJECTIVE

CC: "I'm more short of breath and wheezing than usual, and I’ve been coughing up more phlegm for three days."

HPI: J.T. is a 69-year-old African Caucasian male with a known 10-year history of COPD (GOLD Stage II, moderate) who presents with a 3-day history of worsening shortness of breath, increased cough, and production of thick yellow-green sputum. He denies fever but reports mild chills. He notes increased fatigue and difficulty sleeping due to coughing fits. He uses his albuterol inhaler more frequently (every 2-3 hours vs. usual 1-2 times per day). No recent travel, no known sick contacts. Reports adherence to tiotropium daily but ran out of medication 5 days ago. Denies chest pain, hemoptysis, or leg swelling. No recent ED visits or hospitalizations.

PMH:

· COPD (GOLD II)

· Hypertension

· Hyperlipidemia

· GERD

Surgical History:

· Appendectomy (age 20)

· Right hip replacement (2020)

Allergies:

· NKDA

Medications:

· Tiotropium bromide 18 mcg inhaled once daily (LAMA)

· Albuterol 90 mcg inhaler PRN

· Lisinopril 10 mg daily

· Atorvastatin 20 mg nightly

· Omeprazole 20 mg daily

Vaccination History:

· Influenza: Oct 2024

· Pneumococcal (PPSV23 and PCV15): up-to-date

· COVID-19: Last booster Nov 2024

Social History:

· Former smoker (40 pack-year history), quit 5 years ago

· Occasional alcohol use; denies recreational drugs

· Retired mechanic; lives with wife; enjoys gardening

· Moderate physical activity limited by dyspnea

Family History:

· Father: deceased age 72, MI

· Mother: alive age 90, HTN

· Siblings: Two brothers with hypertension

· Maternal Grandmother CHF

· Maternal grandfather, colitis

· Paternal Grandmother COPD

· Paternal grandfather

ROS:

· General: Reports increased fatigue; denies weight loss

· HEENT: No headache, no sinus congestion

· Cardiovascular: Denies chest pain or palpitations

· Respiratory: (+) Dyspnea, (+) increased cough, (+) sputum production, (+) wheezing

· GI: Denies nausea or abdominal pain

· MSK: Mild exertional fatigue, no joint pain

· Neuro: Denies dizziness, no confusion

· Psych: Mild anxiety due to breathing issues

OBJECTIVE

Vital Signs:

· Temp: 98.2°F

· BP: 138/78 mmHg

· HR: 94 bpm

· RR: 24/min

· SpO₂: 89% on room air

· Ht: 70 in

· Wt: 198 lbs

· BMI: 28.4

Physical Exam:

· General: Mild respiratory distress; alert and oriented x4

· Skin: Warm, no cyanosis or pallor

· HEENT: Oropharynx clear; nasal mucosa mildly inflamed

· Neck: No lymphadenopathy or JVD

· Lungs: Diffuse expiratory wheezes; decreased breath sounds bilaterally; no rales

· Cardio: Regular rhythm, no murmurs

· Extremities: No edema, cap refill <2 sec

· Neuro: No focal deficits

Diagnostics:

· Pulse oximetry: 89% on RA → improved to 94% on 2L nasal cannula

· Chest X-ray: Ordered – pending

· CBC/CMP: Ordered – pending

· COVID-19 and Influenza rapid swab: Negative

ASSESSMENT

Primary Diagnosis:

1. Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) – J44.1

Over the last three days, the patient has developed AECOPD symptoms, include severe dyspnea, wheezing, and sputum volume and color changes. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), an acute exacerbation is a rapid worsening of respiratory symptoms requiring further medication (Franklin et al., 2021). Additionally, the patient's increasing albuterol inhaler usage and recent tiotropium nonadherence destabilize symptoms. The lack of fever and improvement in oxygen saturation with supplementary oxygen suggest simple AECOPD without pneumonia. This is the most likely diagnosis given his mild COPD history and clinical appearance.

Differential Diagnoses:

2. Acute Bronchitis – J20.9

Acute bronchitis presents similarly to AECOPD, with symptoms such as increased cough, sputum production, and wheezing. However, this diagnosis is less likely. CAP remains a possible but less likely differential in this patient. Increased sputum production and systemic symptoms such as chills raise concern for a bacterial infection; however, the absence of fever, pleuritic chest pain, and localized findings on lung auscultation (e.g., crackles or egophony) reduce the likelihood of pneumonia (Singh et al., 2024). Furthermore, his oxygenation improved with low-flow oxygen therapy, which would be atypical in moderate to severe CAP. A chest X-ray is pending and will help confirm or exclude this diagnosis, but the clinical presentation currently favors a non-infectious AECOPD rather than an alveolar infiltrative process consistent with pneumonia..

3. Community-Acquired Pneumonia (CAP) – J18.

CAP remains a possible but less likely differential in this patient. Increased sputum production and systemic symptoms such as chills raise concern for a bacterial infection; however, the absence of fever, pleuritic chest pain, and localized findings on lung auscultation (e.g., crackles or egophony) reduce the likelihood of pneumonia (Regunath & Oba, 2024). Furthermore, his oxygenation improved with low-flow oxygen therapy, which would be atypical in moderate to severe CAP. A chest X-ray is pending and will help confirm or exclude this diagnosis, but the clinical presentation currently favors a non-infectious AECOPD rather than an alveolar infiltrative process consistent with pneumonia.

4. Heart Failure Exacerbation – I50.9

Heart failure exacerbation can mimic respiratory conditions such as AECOPD, particularly with symptoms like dyspnea and fatigue. However, this patient lacks hallmark features of volume overload, including peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, and jugular venous distension (Malik et al., 2025). Lung examination does not reveal bibasilar crackles, and the patient's SpO₂ levels improved rapidly with oxygen therapy, which is more characteristic of obstructive pulmonary issues rather than cardiac decompensation. Additionally, there is no past medical history or supporting clinical evidence for heart failure, making this a much less likely cause of his current symptoms.

PLAN

Diagnostics:

· Chest X-ray (to rule out pneumonia)

· CBC with diff, BMP (to assess infection, electrolytes)

· Sputum culture if symptoms persist

· Consider spirometry at follow-up if symptoms resolve (Singh et al., 2024).

Treatment:

· Prednisone 40 mg PO daily x 5 days (no taper needed) – GOLD, 2024

· Azithromycin 500 mg PO day 1, then 250 mg daily x 4 days (if bacterial infection suspected based on sputum/purulence) – GOLD, 2024

· Albuterol inhaler 90 mcg: 2 puffs q4h PRN SOB

· Tiotropium 18 mcg inhaled daily – Reinstitute LAMA therapy

· Oxygen therapy: 2L via nasal cannula to maintain SpO₂ ≥ 90%

Education:

· Educated on signs of worsening COPD: increased sputum, fever, worsening SOB

· Avoid exposure to tobacco smoke, pollutants, cold air

· Importance of medication adherence, especially tiotropium

· Discussed correct inhaler technique and spacing medications (Marko et al., 2025)

· Encourage pulmonary hygiene: hydration, expectoration techniques

· Avoid alcohol while on antibiotics

· Use spacer with albuterol if needed

· Reviewed potential side effects of prednisone and azithromycin

Follow-up:

· Follow up in 48-72 hours to assess response

· Return sooner if symptoms worsen (e.g., fever, hemoptysis, chest pain, confusion)

· Encourage yearly spirometry to monitor lung function

· Refer to pulmonary rehab if patient continues with functional decline

· Influenza and pneumococcal vaccine reminders at next visit if not up to date

References

Franklin, B. J., Li, K. Y., Somand, D. M., Kocher, K. E., Kronick, S. L., Parekh, V. I., Goralnick, E., Nix, A. T., & Haas, N. L. (2021). Emergency department provider in triage: Assessing site‐specific rationale, operational feasibility, and financial impact. Journal of the American College of Emergency Physicians Open, 2(3). https://doi.org/10.1002/emp2.12450

Malik, A., Chhabra, L., & Shams, P. (2025). Congestive heart failure. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/

Marko, M., Klimczak, M., Sobczak, M., Wojakiewicz, M., Dębowski, T., Emeryk, A., & Pawliczak, R. (2025). Effective inhaler technique education is achievable - assessment and comparison of five inhaler devices errors. Frontiers in Pharmacology, 16. https://doi.org/10.3389/fphar.2025.1538283

Regunath, H., & Oba, Y. (2024). Community-acquired pneumonia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430749/

Singh, A., Avula, A., & Zahn, E. (2024). Acute Bronchitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/

Singh, D., Stockley, R., Anzueto, A., Agusti, A., Bourbeau, J., Celli, B. R., Criner, G. J., Han, M. K., Martinez, F. J., Montes, M., Ozoh, O. B., Papi, A., Pavord, I., Roche, N., Salvi, S., Sin, D. D., Troosters, T., Wedzicha, J., Zheng, J., & Volgelmeier, C. (2024). GOLD Science committee recommendations for the use of pre- and post-bronchodilator spirometry for the diagnosis of COPD. European Respiratory Journal, 65(2), 2401603–2401603. https://doi.org/10.1183/13993003.01603-2024