W6 Soap Note

Answer

W6 Soap Note

Subjective (S):

            Identifying Data

Initials: J.

Age: 69 years.

Race: Race need to be established.

Gender: Male

Chief Complaint (CC): “not sleeping at night because of a constant cough”. 

History of Present Illness (HPI): J. is a 69-year old male who complains of not sleeping at night because of a constant cough. Current symptoms include weight gain (+25 pounds) over the last seven months, and dyspnea on exertion. He coughs up a pink frothy ‘spit and presents with 3+ pitting edema on the lower extremities with coolness to tough.  Other notable symptoms and signs include hacking cough, hepatomegaly, distended abdomen, and S3 with a gallop.

Past Medical History (PMH): He has history of myocardial infarction (15 years ago) and is currently on medication for hypertension.

Allergies: Ask the patient about drug/food allergies.

Current medications: Hypertension medications/not specified.

Immunization: Ask the patient about immunization status.

Prior Hospitalizations: History of hospitalization should be established. 

Prior surgeries: Not asked.

Family History (FH): Not asked.

Social History (SH): Not asked.

Review of Systems (ROS):

1. Constitutional symptoms: Issues that should be established include ambulation status, level of alertness and conscious. He should assed for fever, loss of appetite, or night sweats.
2. Head, Ears, Eyes, Nose, Mouth, and Throat: Head: He should be assessed for injuries, headache or vertigo. Ears: He should be assessed be assessed for discharge or hearing difficulties. Eyes: redness or visual abilities should be established. Nose: Aspects such as sneezing or nasal discharge need be established. Mouth: He coughs up pink frothy “spit”. Throat: He should be investigated whether there is pain on swallowing.
3. Cardiovascular: Shortness of breath at night that disrupts sleep. Dyspnea on exertion.
4. Respiratory: Coughing up pink frothy “spit”, shortness of breath at night. Hacking cough.
5. Gastrointestinal: Abdominal pain, acid reflux, or thirst need be established.
6. Genitourinary: Frequency, rate and volume need be established.
7. Musculoskeletal: Joint/ muscle weakness/pain should be established.
8. Neurologic: Numbness or loss of sensation, generalized body weakness or tingling sensations should be asked.
9. Psychiatric: Lack of sleep.
10. Endocrine: History of endocrine disorders should be established.
11. Hematologic/lymphatic: History of lymphatic disorders or hematological disorders need to be established.
12. Allergic/immunologic: Need to be established.

OBJECTIVE DATA

1. Constitutional: VS: such as temperature; blood pressure; heart rate; respiratory rate, height, and weight should be evaluated.
2. General appearance: Level of consciousness, alertness, and ambulation status should be established.
3. HEENT: Head: head shape and size as well as head injuries need be evaluated. Eyes: objective assessment of the eyes. Ear: hearing and other issues should be established. Nose: Nose assessment. Mouth: Assessment for cyanosis. Throat: Presence of erythema of the nasopharynx should be established. Any decaying or missing teeth?
4. Cardiovascular: S3 detected. Any chest pain. Is heat rhythm regular heart rhythm and rate (Inamdar & Inamdar, 2016)?
5. Respiratory: Pink frothy sputum. Assessment for respiratory sounds.
6. Gastrointestinal: Characteristics of bowel sound?
7. Genitourinary: Glomerular filtration rate? Any bladder incontinence or pain during urination?
8. Musculoskeletal: Range of motion in all extremities?  
9. Integumentary/lymphatic: 3+ pitting edema. Skin texture and softness? Any lumps?
10. Neurologic: Oriented to place, time, and person?

Diagnostic Testing:

• Electrocardiography
• Assessment for myocardial infarction (Vahhatpour, Collins, & Goldberg, 2019).
• Assessment for excess fluid volume.

Assessment (A):

            Differential diagnoses:

• Heart failure: Signs and symptoms include 3+ pitting edema, breathlessness on exertion, weight gain (25 pounds over the last 7 months), S3 gallop, and a cough. Heart rhythm and blood pressure should be established (Vahhatpour, Collins, & Goldberg, 2019). It is a potential differential diagnosis.
• Myocardial infarction: History of myocardial infarction, and shortness of breath. No chest pain, chest tightness, or nausea; thus, this differential diagnosis may be ruled-out (Inamdar & Inamdar, 2016).
• Excess fluid volume: Rapid weight gain, 3+ pitting edema, shortness of breath, abdomen distension. Blood pressure and headache need to established since this is another potential differential diagnosis (Diepen et al., 2017).

Plan (P): Fluid control and assessment of potential kidney failure or cardiogenic shock (Diepen et al., 2017; Vahhatpour, Collins, & Goldberg, 2019).

Patient Education: Dietary and lifestyle changes (Vahhatpour, Collins, & Goldberg, 2019).