fbpx

Dyspnea SOAP Note Example

Dyspnea SOAP Note Example

Develop a SOAP Note for a patient you care for in clinical who complained of dyspnea. Remember to include differential Diagnoses and Diagnostics. 

Dyspnea: Differential Diagnosis & Treatment Plan

SUBJECTIVE

Chief Complaint: The male patient aged 60 years has a history of mild chronic obstructive pulmonary disease with complaints of dyspnea, cough, fever, and fatigue that gradually worsened over the last seven days.

History Patient Illness: The patient states his dry cough, weakness, and fatigue commenced one week ago. Shortly afterward, the coughing became productive, accompanied by rust-colored sputum, and gradually increased in the last three days. He also remembers developing symptoms associated with the flu one week before developing the cough and fatigue. The patient presented to the hospital after he began experiencing a mild fever, fatigue, and substantial dyspnea with minor exertions from walking and slight exercise. The dyspnea is exacerbated by physical exertion and alleviated by rest. The patient reports that he has been staying awake during the night and sleep sitting upright or with three pillows to relieve the dyspnea. The patient states that he has a medical history of COPD and pneumonia treated using antibiotics by his primary care provider. Also, he has been using his albuterol inhaler thrice every day, which has helped slightly.  The patient denies a history of chest pain, diabetes, heart, and lung disease, but there has been an increase in heart rate and chest tightening whenever he coughs. No recent travel and weight change. He is presently a non-smoker but used to smoke one pack daily for about 2 decades before quitting three years ago.

Allergies: None

Medication: HCTZ 25 milligram daily, albuterol MDI PRN, and simvastatin 20 milligrams daily

Surgeries: Cholecystectomy ten years ago

Past Medical History: The patient is presently getting treatment for hyperlipidemia, hypertension, and chronic obstructive pulmonary disease.

Immunization: Up to date

Family history:  Mother: died at 80 years breast cancer

Father: died at 82 years from acute myocardial infarction

Sister: alive, 60 years old, hyperlipidemia and hypertension

Son: Healthy, alive and no medical complications, 40 years

Social History: Non-smoker and social drinker. He has retired and lives with his son. The wife died ten years ago from breast cancer.

Review of Symptoms: Constitutional- as stated above

General: Shortness of breath, fatigue, nausea, weakness, loss of appetite, and hemoptysis

Head: Denies headache and dizziness

Skin:  Denies rash, pruritis, and jaundice.

Eyes- Denies vision change and pain; ears- Denies tinnitus and change in hearing; nose: positive rhinitis and nasal congestion; denies epistaxis; Mouth & Throat: the presence of throat dryness and soreness, but negative dysphagia and sores; Neck- negative for neck pain and swelling.

Respiratory: Productive cough with greenish sputum and shortness of breath

Cardiovascular- Tachycardia and PND, but no history of cardiovascular disease.

GI- Negative abdominal distress, vomiting, constipation, diarrhea, and melena

GU- Negative dysuria, hematuria, and nocturia.

Endocrine- No hypothyroidism and diabetes history. Denies history of cold or heat intolerances or changes in skin and hair. Denies polyuria and polydipsia.

Neurological: Denies numbness and tingling

Order from Course ResearchersDevelop a SOAP Note for a patient you care for in clinical who complained of dyspnea
Order a Customized One for $12 per Page/275 words

OBJECTIVE

Vital Signs

Vitals: T-102o F, P-104, R-30, BP-126/87, PO2-95% on room air, Height-5’9” Weight-195 pounds BMI-28.9

Physical Examination

General Appearance: The patient is tachypneic with no use of accessory muscle.

HEENT: TM pearly gray sound cone of the light bilateral, non-tender maxillary sinus, moist nasal mucosa, and presence of clear discharge with no bleeding. Dry oral mucos but no lesions, and oropharynx erythematous.

Neck: Positive for the supple neck with moderate cervical lymphadenopathy, negative presence of jugular vein distention, thyroidomegaly, and thyroid masses.

Skin: Negative cyanosis, lesions, and rashes.

Cardiovascular: RRR, S1S2, no gallops, and murmurs. Radial pulses and DP equal bilateral. Negative for lower extremities edema and capillary refill below two seconds.

Lower extremity: Negative edema and tenderness. The calves are equal-sized bilateral

Abdomen: Soft, no tenderness, distension, pulsatile masses, bruits, and organomegaly. Active or bowel sounds

Lungs: Crackles auscultated posteriorly left lung base, presence of moderate expiratory wheezing in left chest and egophony in lowermost portion left lower lobe. Breathing sounds in the right lung faintly diminished with no adventitial sound.  There is no presence of egophony in the right lung, and accessory muscles use.

Lab Tests: CBC: RBC- 5.40, WBC-17.10, Hct- 39.0%, Neutros- 82.0%, Hgb-12.2, Platelet 252,000. Cl-101.0, Na- 140.0, bicarb-23.0, K- 3.70, BUN- 17, BNP- 45 Creat- 0.90

Chest X-ray: Consolidation area located left lower lobe, suspect minimally pleural effusion in the left lung. The remainder bilateral lung parenchyma reveals emphysematous change with moderate hyperexpansion.

ASSESSMENT

The patient complaints: productive cough, dyspnea, fatigue, and fever.

Diagnosis:

Pneumonia: Suspected pneumonia organism due to the presence of the onset and high fever and chest x-ray image with consolidation.

Differential Diagnosis:

Congestive heart failure

Acute exacerbation chronic bronchitis

Pulmonary embolism

PLAN

The initial task was to determine whether the patient could be treated either as outpatient or hospitalization was required. Due to costly hospital services, risks of nosocomial infections, and no comorbidity, available clinical decision support recommended that the patient could be treated successfully on an outpatient basis. The outcome was proper management by controlling symptoms and improving quality of life. The Infectious Diseases Society of America recommends specific therapy and treatment guidelines. An empirical treatment plan was initiated by IV azithromycin and IV cefotaxime Medrol dose pack taper. Also, Albuterol nebulizer treatment each 4 hour PRN. For COPD, the treatment was Albuterol and Medrol dose pack. The hydrochlorothiazide and simvastatin were continued.  The patient was contacted within 24 of commencing therapy and scheduled for office visits at one week and 4 weeks after initial evaluation. Examination in follow-up would include a chest x-ray film if the symptoms were not resolved.

References

Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.

McConaghy, J. R., & Oza, R. S. (January 01, 2013). Outpatient diagnosis of acute chest pain in adultsAmerican Family Physician, 87, 3, 177-182.

Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.

error: Content is protected !!