QUESTION
SOAP format
W5.----2 pages---
SOAP format
Case:
Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5
Then,
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
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| Subject |
Nursing |
Pages | 5 | Style | APA |
|---|
Answer
Soap Note
SUBJECTIVE INFORMATION
Patient Initials: D.E
Age: 56
Gender: Female
Chief Complaint (CC):“I have cold that has been occurring for several weeks and will not just go away”
History of Patient illness (HPI): A 56-year-old female presents to the hospital complaining that she has been having cold that will not go away. The patient states that she has a dry hacking cough, headache and muscle aches. She adds that while it is very hot, she still shivers in a sweater. The patient states that she has been trying over-the-counter medication but nothing has changed. The patient concludes by saying that she feels tired and fatigued.
Allergies: NKDA
Current medication: No current medication
Past illness: Hospitalized because of high blood pressure
Immunization: Immunization records are up-to-date. .
Surgical history: No history of surgery
Family history: The patient states that her father died 20 years ago as a result of heart attack. The mother is a live but hypertensive. She has three kids with no significant medical issue. The husband is also hypertensive which is managed effectively using medication.
Social history: The patient occassionally drink wine but does not smoke. However, the husband is a smoker.
Review of system (ROS):
General: The patient states that she is tired and fatigued.
HEENT: The head is symmetric with no injuries. Does not report pain or discharge from the ear. She denies vision problems, dryness of the eye or any discharge. Does not report any form of bleeding. She denies mucosa stiffness, tongue sores, and sinus congestion.
Respiratory: Reports shortness of breath and difficulty breathing, and cough sputum production. Reports crackle and wheezing sound while breathing.
Cardiac: Reports chest discomfort. She denies palpitations, or edema.
Gastrointestinal: No swallowing problem, denies bowel movement changes, heartburn, orabdominal pain.
Genitourinary: She denies itching or dysuria masses.
Musculoskeletal: She reports muscle pain.
Psychiatric: Reports no signs of psychiatric problem
OBJECTIVE
The patient appears tired and fatigued but responsive to questions. She is also neat.
Vital signs: BP 130/80; P 84; R 14; T 100.5; Pulse ox: 94%
Head: No facial rashes
Eyes: No visual impairment and the eyes are responsive to light
Ears: all canals are very clear: no discharge
Nose: no discharge
Mouth/throat: no dry mouth, no sore tongue, no hoarseness,
Cardiovascular: asymmetries, dullness on percussion over her left lower lobe
Respiratory: Crackles are auscultated posteriorly over the left lung at the base. Mild expiratory wheezes are heard in the left chest. The right lung breath sounds are slightly diminished.
Gastrointestinal: No changes in swallowing, appetite, heartburn or abdominal pain.
Musculoskeletal: No swollen joints
Psychiatric: No history of depression, stress, or anxiety.
Diagnostics
CBC w/ differentials: Pending
Influenza testing include nasopharyngeal: Positive for influenza.
Chest x-ray: Pending
Rapid antigen swab test for strep throat: Negative.
ASSESSMENT
Differential diagnoses
- Influenza. This is a highly contagious viral disease of the respiratory that involves nasal mucosa, pharynx, and conjunctiva. Some of the common symptoms include fever, difficulty breathing, chills, and congestion, cough, and muscle pains (Luo et al., 2020). All these symptoms have been presented by the patient. Additionally, it has been confirmed with a positive influenza test.
- Streptococcal pharyngitis. This acute inflammation of the pharynx that is caused by viruses. It is ruled out in this case since the patient tested negative for rapid antigen swab test (Bordi et al., 2020).
- Respiratory syncytial Virus. This is a disease of the lower respiratory that is also caused by viruses. One of the ways of confirming the existence of the disease is through sputum test which is pending in this case.
Plan
- 5ml Phenergan with Codeine for seven days
- 10mg Zyrtec on a daily basis for 10 days
- 500mg Tylenol on a daily basis will be appropriate for pain control (Luo et al., 2020).
- The patient was also educated to take a lot of water and other liquid substances
- The patient was also told to avoid contact with others to prevent spread of the disease
- Follow up was also scheduled after one week to assess the response to drugs and any possibility of adverse drug side effects.
References
Bordi, L., Nicastri, E., Scorzolini, L., Di Caro, A., Capobianchi, M. R., Castilletti, C., & Lalle, E. (2020). Differential diagnosis of illness in patients under investigation for the novel coronavirus (SARS-CoV-2), Italy, February 2020. Eurosurveillance, 25(8), 2000170.
Luo, Y., Yuan, X., Xue, Y., Mao, L., Lin, Q., Tang, G., ... & Sun, Z. (2020). Using the diagnostic model based on routine laboratory tests to distinguish patients infected with SARS-CoV-2 from those infected with influenza virus. International Journal of Infectious Diseases.