Wk2: Respiratory Clinical Case APN

SOAP NOTE

Name:	Date:	Time:
	Age:	Sex:
SUBJECTIVE
CC:  Reason given by the patient for seeking medical care “in quotes”
HPI:  Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH Allergies:    Medication Intolerances:   Chronic Illnesses/Major traumas   Hospitalizations/Surgeries   “Have you every been told that you have:  Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status
ROS
General Weight change, fatigue, fever, chills, night sweats,  energy level	Cardiovascular Chest pain, palpitations, PND, orthopnea, edema
Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles	Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
Eyes Corrective lenses, blurring, visual changes of any kind	Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears Ear pain, hearing loss, ringing in ears, discharge	Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS    Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx   Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain	Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
Breast SBE, lumps, bumps or changes	Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance	Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
Weight        BMI	Temp	BP
Height	Pulse	Resp
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable. (Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests Urinalysis – pending Urine culture – pending Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses · 1- · 2- · 3- Diagnosis
Plan/Therapeutics
· Plan: · Further testing · Medication · Education · Non-medication treatments
Evaluation of patient encounter

RESPIRATORY CARE PLAN 1

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3

RESPIRATORY CARE PLAN

 

Respiratory Care Plan

James Bostick

South University Online

Dr. Cynthia Bostick

NSG 6001

May 6, 2020

 

Patient Initials JD

Subjective Data: 65-year-old female patient reports to the clinic today stating that she has been experiencing wheezing, shortness of breath, and coughing at least once daily. Patient further states that she is struggling to speak without pausing her speech to catch her breath and states affirms that she has taking her medication (albuterol) once today.

Chief Complaint: Severe wheezing, shortness of breath, and coughing at least once daily.

History of Present Illness: Patient presents repeated asthma attacks for the past 2 months (averaging more than 4 times per week). There is a record of a MVA 10 weeks ago, followed by a post traumatic seizure 2 weeks after the initial accident. Patient started on anticonvulsant drug Phenytoin. Negative seizure activity reported after commencement of drug therapy.

Medical History: History of episodic asthma attacks since the patient was in early 20s. Patient currently taking Theophylline BID and an Albuterol Inhaler PRN. Patient was diagnosed with mild congestive heart failure 3 years ago. Patient placed on sodium restrictive diet and Hydrochlorothiazide BID. Last year the patient was placed prescribed Enalapril BID due to worsening CHF. As a result, symptoms effectively controlled last year. Wk2: Respiratory Clinical Case APN

Surgical History: Patient denies

Allergies: NKDA

Medication List:

· Theophylline SR Capsules 300 mg PO BID for asthma

· Albuterol Inhaler, PRN for asthma

· Phenytoin SR Capsules 300 mg PO QHS for seizures

· Hydrochlorothiazide (HCTZ) 50 mg PO BID for congestive heart failure (CHF)

· Enalapril 5 mg PO BID for congestive heart failure (CHF)

Significant Family History: Patient’s father died at age 59 related to complications with kidney failure secondary to HTN. Patient’s mother died at age 62 as a result of CHF complications.

Social History: Denies being a smoker; denies alcohol. Patient admits to caffeine use: 4 cups of coffee and 4 diet colas per day.

Review of Symptoms: Patient was positive for shortness of breath, coughing, and wheezing and exercise intolerance. Patient denies headache, swelling in upper and lower extremities and/or seizures.

Objective Data:

Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’3” BMI 26.2

*VS after Albuterol breathing treatment – BP 134/79, HR 80, RR 18

Physical Assessment Findings:

General: Well developed female appearing anxious

Integumentary: Skin pale, no bruising noted

HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted

Cardiovascular: Regular rate and rhythm normal S1 and S2.

Respiratory: Bilateral expiratory wheezes

Gastrointestinal: Guaiac negative, abdomen soft, non-tender, non-distended with no masses

Genitourinary: Unremarkable

Musculoskeletal: +1 ankle edema on right, palpable pulses in all extremities

Neurological: A/OX3, all cranial nerves intact

Endocrine: Unremarkable

Hematologic: Unremarkable

Psychological: Patient anxious

Laboratory Test Results:

Actual Value Reference Value Conventional U.S. Unit

Na – 134 (134-142) mEq/L

K – 4.9 (3.7-5.1) mEq/L g/mL

Cl – 100 (98-108) mEq/L

BUN – 21 (6-25) mg/dL

CR – 1.2 (0.4-1.1) mg/dL

Glu – 110 (62-110) mg/dL

ALT – 24 (5-40) U/L

AST – 27 (5-40) U/L

Total Chol -190 (<265) mg/dL *women >50 yr

CBC – WNL

Theophylline – 6.2 (5-20) ug/mL

Phenytoin – 17 (10-20) ug/mL

 

(Fischbach & Dunning, 2017)

 

Diagnostic Test Results:

Chest Xray – Blunting of the right and left costophrenic angles

Peak Flow – 75/min; after Albuterol – 102/min

FEV1 – 1.8 L; FVS – 3.0 L; FEV1/FVC – 60%

Assessment:

J45.31 Mild persistent asthma with (acute) exacerbation

I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

J44.9 Chronic obstructive pulmonary disease, unspecified

 

Plan of Care:

Diagnosis: J45.31 Mild persistent asthma with (acute) exacerbation

Education: Asthma is a chronic inflammatory disorder of that affects the lungs. Asthma causes chest tightness, coughing, wheezing and shortness of breath. Being exposed to things in the environment, like mold or dampness, some allergens such as dust mites, and secondhand tobacco smoke have all been linked to developing asthma and asthma exacerbation (CDC, 2019). Environmental and occupational factors have also been linked to asthma.

Goals: One goal for asthma management would be to prevent asthma exacerbations. Factors such as pollen and dusk can exacerbate the condition and cause further complications such as an asthma attack. Another goal for would be to limit stress. The patient came into the clinic very anxious. Stress-induced asthma can make inflammation worse, triggering breathing difficulties in the patient which could also lead to an asthma attack.

Therapeutic Management: Patients should take prescribed medications and adhere to medication regimen. Reducing stress and avoiding air pollution and allergens that may cause a flare in the condition. Patients should seek medical treatment immediately if their symptoms persist and/or get worse (CDC, 2019).

Evaluation: Individuals with asthma should monitor their breathing and follow up with their PCP to evaluate their progress. Frequency of symptoms is another key feature of the evaluation, focusing on the number of times per week the patient experience symptoms and whether they occur during the day or night (Corren, 2020).

Diagnosis: I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

Education: Heart failure occurs when your heart muscle fails to pump blood as well as it should. According to the CDC (2019), it is estimated that 6.5 million adults in the United States suffer from this condition. Symptoms of CHF include, weight gain with swelling in the lower extremities, weakness, shortness of breath and difficulty breathing while lying down.

Goals: Some of the goals of treating heart failure are primarily geared toward decreasing the likelihood of exacerbation and/or disease progression. Limiting the symptoms of CHF thereby decrease the chances of mortality.

Therapeutic Management: Both early diagnosis and treatment of CHF can help improve the quality for people suffering. Treatment involves taking your medications as prescribed, reducing sodium intake, drinking less liquids, proper dieting and exercise to decrease weight, particularly in obese patients, etc.

Evaluation: People living with CHF should readily track their symptoms and discuss them with their PCP. Importance of recording fluid intake, weight and vital signs are all equally important.

Diagnosis: J44.9 Chronic obstructive pulmonary disease, unspecified

Education: Chronic obstructive pulmonary disease or “COPD,” refers to a collective of diseases that cause both breathing problems and problems with airflow blockage. Chronic bronchitis and emphysema are the two most common conditions of COPD. Similar to asthma, symptoms of this disease include dyspnea on exertion, wheezing, chest tightness, cough, etc.

Goals: The goals of effective COPD management include relief of symptoms, preventing disease progression and improving exercise tolerance to name a few.

Therapeutic Management: Management of COPD would rely on the use of bronchodilators such as Spiriva. Also, stopping smoking decreases a patient’s chances of exacerbation. Furthermore, lung therapies such as oxygen therapy and pulmonary rehab programs, could prove effective in the treatment of this disease (CDC, 2019).

Evaluation: It’s important that patients with COPD are followed by a pulmonolgist. Arterial blood gas analysis (ABG) and /or spirometry would be recommended by doctors to evaluate the function of the lungs. Patients should also monitor for an increase in symptoms that last without relief. Wk2: Respiratory Clinical Case APN

 

 

 

References

Centers for Diseases Control and Prevention (CDC). (2019). Asthma. Retrieved from https://www.cdc.gov/asthma/faqs.htm.

Centers for Disease Control and Prevention (CDC). (2019). Chronic obstructive pulmonary disease. Retrieved from https://www.cdc.gov/copd/index.html.

Corren, J. (2020). Evaluation and treatment of asthma: An overview. Retrieved from https://www.ajmc.com/journals/supplement/2005/2005-11-vol11-n14suppl/nov05-2211ps408-s415.

Fischbach, F. & Dunning, M. (2017). A manual of laboratory and diagnostic tests (10th ed.). Philadelphia, PA: F.A. Davis. ISBN: 9780803667181.