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– 2 years ago **files (1)** – ## Soapnote1.docx **## Soapnote1.docx** Name: Mrs. A. M. Age: 45-years-old Date of Birth: 21st February 1976 Referrals: None Gender: Female Source: Patient HPI: For the past week, the patient has been complaining of a dry cough and exhaustion. Shortness of breath is als…
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– 2 years ago
**files (1)**
– ## Soapnote1.docx
**## Soapnote1.docx**
Name: Mrs. A. M.
Age: 45-years-old
Date of Birth: 21st February 1976
Referrals: None
Gender: Female
Source: Patient
HPI: For the past week, the patient has been complaining of a dry cough and exhaustion.
Shortness of breath is also a problem for the patient, particularly when she is exercising. His
sputum turned green three days ago, and he developed a fever. The patient's heart rate is in the
80s to 90s. She is still complaining of chest pains and exhaustion, to the point that she is unable
to exercise her morning routine. This is an urgent problem since she is suffering from severe
right hip pain. The pain was described as an 8/10 by the patient and lasted for two weeks. Patient
has a history of injuries from when she was in college playing volley ball.
PMH: She was diagnosed with hypertension four years ago and takes medicine to manage it. She
was diagnosed with COPD two years ago and is now on medication. In addition, Asthma, benign
prostatic hypertrophy, coronary artery, osteoarthritis, hyperlipidemia and syncopal episodes have
been significantly recorded in medical history in the past.
Current Medications:
Fluvastatin 20mg PO daily
Lisinopril 40 mg PO once a day for hypertension.
Combivent-Two inhalations that are performed three times a day.
Allergies: Pollen
Immunization: Up-to date. She last got her vaccinations in 2020 November.
Surgical History:
• After an appendectomy in 2002, she claimed that she was on the verge of passing
away due to pain.
• Her tonsils were removed at a young age.
Family History:
Mother: Still alive but diagnosed with lung cancer.
Father: Deceased in 2000 from brain tumor
Husband: 50-years-old. Works as an Accountant.
Brother: 70-year-old. He is alive but has been having heart problems for the last 2 years.
Children: Patient has 2 sons and 1 daughter both are in high school.
Social History: The patient used to smoke cigarettes and drink beer every Friday night when she
was young. She gave up all of that more than two decades ago. She now enjoys planting and
reading inspirational novels.
Drug use History: Quit smoking one pack of cigarettes. No drug usage for her at the moment
Physical Examination
Chief Complaint: Patient complains and states that, “She has been having persistent coughs for
the past week.”
Analysis of the Symptoms: With a heart rate in the 80s to 90s, the patient experiences shortness
of breath especially when she is coughing. She also complains of chest pains and exhaustion, to
the point that she is unable to complete her morning routine. Since she has serious right hip pain,
this is an urgent concern. The pain is rated as an 8/10 by the patient and has lasted for two weeks.
Review of Symptoms (ROS)
Constitutional: Chills are recorded along with a decrease in appetite. The patient, on the other
hand, refuses any sweetening, weight loss, or changes in sleeping patterns.
Head or Face: Denies the feeling of dizziness which causes headache in the past or the present.
EENT: Eyes: Denies that she has short vision and suggests that she wear optical glasses. Ears:
Despite the fact that he will need a hearing aid, the patient denies having any illness or hearing
loss. Nose: Says she doesn't have any nasal discharge or pains. Throat: Denies getting a sore
throat or speaking with a hoarse voice. The mouth does not have a breath odor. The patient's last
EENT checkup was three years ago.
Respiratory: The patient complains of chest pain and a dry cough that worsens in the morning.
She experienced shortness of breath about a week ago and found that the color of his sputum had
shifted. Denies having some trouble with her lungs.
Cardiovascular: The patients deny palpitations and irregular quick cardiac beats. She reports
that she's not sleeping well because she has chest pain.
Gastrointestinal: Denies any difficulties with excretion or pattern alteration. Hematemesis is
reported to have been treated for 5 years.
Genitourinary: While urinating, she denies getting any discharge or a change of color. There
have been reports of a mild burning feeling.
Musculoskeletal: Denies any recent injuries, but admits to having severe hip and joint pains.
Skin: Denies have excess sweat, rashes, irregular pimples and skin pigmentation changes.
Diagnostic Considerations
Vital Signs: T 101.80F, BP 125/87, HR 99/min, RR 32/min, Ht 5”9’, Wt 192lbs, BMI 24.3,
SpO2: 95% on room air
General Appearance: The patient appears healthy, no signs of stress and makes the conversation
lively with the doctor. She is smartly dressed and smiles often
Head and Face: Patients has a neat head with hair. The face has no scars
EENT: Eyes: The pupils are symmetrical and fair, with a black iris in size and form. Extraocular
muscle activity is unaffected. Symmetrical projection of corneal rays on skin, with complete
visual fields. Natural structures and anatomy are revealed from the tests. There are no signs of
inflammation, wax, a foreign body, or discharge in the ears. Observation of the tympanic
membrane reveals a cone of light. Following certain checks, hearing is found to be fine. Nose:
Mucus is visible in the nasal passage. Throat: The voice is not hoarse.
Respiratory: The patient is coughing and wheezing and has a dry cough. She had a habit of
coughing while speaking.
Cardiovascular: When the patient exercises, she experiences chest pains and rapid heartbeats.
Gastrointestinal: The abdomen is soft and the patient has no masses. The sounds of the bowels
are audible.
Skin: Patients skins is clean and dry. It is evident she has no rashes or lesions.
Diagnostic Workup
Main Diagnosis: Acute Pneumonia
A number of signs and symptoms associated with fever > 100°F (38°C), lower respiratory
tract inflammation, cough, expectoration, chest pain, dyspnea, and signs of alveolar space
invasion are used to make a clinical diagnosis (Jarvis, 2016). Older patients, in particular, are
often afebrile and may exhibit anxiety as well as worsening of underlying diseases.
Differential Diagnosis
The clinical symptoms of pneumonia in older adults are usually progressive and unspecific,
causing exhaustion, drowsiness, diarrhea, and headache. Fever, chills, extreme pleuritic chest
pain, tachycardia, tachypnea, dry or painful cough, dyspnea, diarrhea, tiredness, myalgia,
hypoxia, excessive sweating, and abdominal pain are some of the symptoms that can occur.
Pneumonia may cause older adults to fall or become confused.
Summary
Non-Pharmacologic treatment
1) Relax and rest.
2) Respiratory Monitoring checkups
3) Quitting smoking.
4) Avoiding second-hand smoke.
5) Positioning should be semi-upright or straight.
6) Drinking a lot of fluids
Pharmacologic treatment
1) Empirical diagnosis is important, because pathogen is often not detectable.
2) Medication Azithromycin (Zithromax): The patient should take 500 mg, then 250 mg of
PO every 72 hours for three days.
3) Influenza vaccine every year
Health Education
• Inform the patient of the importance of following the medication.
• Inform the patient about the importance of pneumococcal vaccination.
• Educate the patient about the benefits of quitting smoking.
Follow-ups/Referrals
Although she is on medication, she has a scheduled appointment in two weeks to assess her
condition and have a chest x-ray
Reference
Jarvis, C. (2016). Pocket companion for physical examination & health assessment (Seventh
ed.)
**## Soapnote1.docx**
Name: Mrs. A. M.
Age: 45-years-old
Date of Birth: 21st February 1976
Referrals: None
Gender: Female
Source: Patient
HPI: For the past week, the patient has been complaining of a dry cough and exhaustion.
Shortness of breath is also a problem for the patient, particularly when she is exercising. His
sputum turned green three days ago, and he developed a fever. The patient's heart rate is in the
80s to 90s. She is still complaining of chest pains and exhaustion, to the point that she is unable
to exercise her morning routine. This is an urgent problem since she is suffering from severe
right hip pain. The pain was described as an 8/10 by the patient and lasted for two weeks. Patient
has a history of injuries from when she was in college playing volley ball.
PMH: She was diagnosed with hypertension four years ago and takes medicine to manage it. She
was diagnosed with COPD two years ago and is now on medication. In addition, Asthma, benign
prostatic hypertrophy, coronary artery, osteoarthritis, hyperlipidemia and syncopal episodes have
been significantly recorded in medical history in the past.
Current Medications:
Fluvastatin 20mg PO daily
Lisinopril 40 mg PO once a day for hypertension.
Combivent-Two inhalations that are performed three times a day.
Allergies: Pollen
Immunization: Up-to date. She last got her vaccinations in 2020 November.
Surgical History:
• After an appendectomy in 2002, she claimed that she was on the verge of passing
away due to pain.
• Her tonsils were removed at a young age.
Family History:
Mother: Still alive but diagnosed with lung cancer.
Father: Deceased in 2000 from brain tumor
Husband: 50-years-old. Works as an Accountant.
Brother: 70-year-old. He is alive but has been having heart problems for the last 2 years.
Children: Patient has 2 sons and 1 daughter both are in high school.
Social History: The patient used to smoke cigarettes and drink beer every Friday night when she
was young. She gave up all of that more than two decades ago. She now enjoys planting and
reading inspirational novels.
Drug use History: Quit smoking one pack of cigarettes. No drug usage for her at the moment
Physical Examination
Chief Complaint: Patient complains and states that, “She has been having persistent coughs for
the past week.”
Analysis of the Symptoms: With a heart rate in the 80s to 90s, the patient experiences shortness
of breath especially when she is coughing. She also complains of chest pains and exhaustion, to
the point that she is unable to complete her morning routine. Since she has serious right hip pain,
this is an urgent concern. The pain is rated as an 8/10 by the patient and has lasted for two weeks.
Review of Symptoms (ROS)
Constitutional: Chills are recorded along with a decrease in appetite. The patient, on the other
hand, refuses any sweetening, weight loss, or changes in sleeping patterns.
Head or Face: Denies the feeling of dizziness which causes headache in the past or the present.
EENT: Eyes: Denies that she has short vision and suggests that she wear optical glasses. Ears:
Despite the fact that he will need a hearing aid, the patient denies having any illness or hearing
loss. Nose: Says she doesn't have any nasal discharge or pains. Throat: Denies getting a sore
throat or speaking with a hoarse voice. The mouth does not have a breath odor. The patient's last
EENT checkup was three years ago.
Respiratory: The patient complains of chest pain and a dry cough that worsens in the morning.
She experienced shortness of breath about a week ago and found that the color of his sputum had
shifted. Denies having some trouble with her lungs.
Cardiovascular: The patients deny palpitations and irregular quick cardiac beats. She reports
that she's not sleeping well because she has chest pain.
Gastrointestinal: Denies any difficulties with excretion or pattern alteration. Hematemesis is
reported to have been treated for 5 years.
Genitourinary: While urinating, she denies getting any discharge or a change of color. There
have been reports of a mild burning feeling.
Musculoskeletal: Denies any recent injuries, but admits to having severe hip and joint pains.
Skin: Denies have excess sweat, rashes, irregular pimples and skin pigmentation changes.
Diagnostic Considerations
Vital Signs: T 101.80F, BP 125/87, HR 99/min, RR 32/min, Ht 5”9’, Wt 192lbs, BMI 24.3,
SpO2: 95% on room air
General Appearance: The patient appears healthy, no signs of stress and makes the conversation
lively with the doctor. She is smartly dressed and smiles often
Head and Face: Patients has a neat head with hair. The face has no scars
EENT: Eyes: The pupils are symmetrical and fair, with a black iris in size and form. Extraocular
muscle activity is unaffected. Symmetrical projection of corneal rays on skin, with complete
visual fields. Natural structures and anatomy are revealed from the tests. There are no signs of
inflammation, wax, a foreign body, or discharge in the ears. Observation of the tympanic
membrane reveals a cone of light. Following certain checks, hearing is found to be fine. Nose:
Mucus is visible in the nasal passage. Throat: The voice is not hoarse.
Respiratory: The patient is coughing and wheezing and has a dry cough. She had a habit of
coughing while speaking.
Cardiovascular: When the patient exercises, she experiences chest pains and rapid heartbeats.
Gastrointestinal: The abdomen is soft and the patient has no masses. The sounds of the bowels
are audible.
Skin: Patients skins is clean and dry. It is evident she has no rashes or lesions.
Diagnostic Workup
Main Diagnosis: Acute Pneumonia
A number of signs and symptoms associated with fever > 100°F (38°C), lower respiratory
tract inflammation, cough, expectoration, chest pain, dyspnea, and signs of alveolar space
invasion are used to make a clinical diagnosis (Jarvis, 2016). Older patients, in particular, are
often afebrile and may exhibit anxiety as well as worsening of underlying diseases.
Differential Diagnosis
The clinical symptoms of pneumonia in older adults are usually progressive and unspecific,
causing exhaustion, drowsiness, diarrhea, and headache. Fever, chills, extreme pleuritic chest
pain, tachycardia, tachypnea, dry or painful cough, dyspnea, diarrhea, tiredness, myalgia,
hypoxia, excessive sweating, and abdominal pain are some of the symptoms that can occur.
Pneumonia may cause older adults to fall or become confused.
Summary
Non-Pharmacologic treatment
1) Relax and rest.
2) Respiratory Monitoring checkups
3) Quitting smoking.
4) Avoiding second-hand smoke.
5) Positioning should be semi-upright or straight.
6) Drinking a lot of fluids
Pharmacologic treatment
1) Empirical diagnosis is important, because pathogen is often not detectable.
2) Medication Azithromycin (Zithromax): The patient should take 500 mg, then 250 mg of
PO every 72 hours for three days.
3) Influenza vaccine every year
Health Education
• Inform the patient of the importance of following the medication.
• Inform the patient about the importance of pneumococcal vaccination.
• Educate the patient about the benefits of quitting smoking.
Follow-ups/Referrals
Although she is on medication, she has a scheduled appointment in two weeks to assess her
condition and have a chest x-ray
Reference
Jarvis, C. (2016). Pocket companion for physical examination & health assessment (Seventh
ed.)