Assignment 2: SOAP Note
Complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week (Gastrointestinal system), and the completed SOAP note should be submitted to the Dropbox. When submitting your note, be sure to include the reference number from eMedley where you entered this specific patient’s case entry.
See the SOAP note template and this example as a reference.
SOAP NOTE R# 4452762
Name: AL
Date:04/14/2017
Time: 1000
Age:67
Sex:M
SUBJECTIVE
CC: “I feel short of breath”
HPI:
Patient 67 y/o male with history of Essential hypertension, Type2 diabetes mellitus, Heart disease and Chronic obstructive pulmonary disease came to the office for a medical evaluation, he refers short of breath that is worse at night since 3 days ago and he was the whole last night sitting on the chair.
Medications: (list with reason for med )
Aldactone 25mg tablet, 1 tablet once a day.
Aspirin 81mg tablet chewable, 1 tablet once a day.
Digoxin 125mcg tablet, 1 tablet once a day.
Amlodipine Besylate 25mg tablet, 1 tablet once a day.
Metformin HCL 850mg tablet, 1 tablet with a meal once a day.
Ibuprofen 800mg tablet, 1 tablet three times a day.
Xarelto 20mg tablet, 1 tablet with food once a day.
PMH
– Essential (primary) hypertension
– Type 2 diabetes mellitus without complications
– Persistent atrial fibrillation- I48.1
– Chronic obstructive pulmonary disease, unspecified
Allergies: NKDA
Medication Intolerances: none
Chronic Illnesses/Major traumas
– Essential (primary) hypertension
– Type 2 diabetes mellitus without complications
– Persistent atrial fibrillation
– Chronic obstructive pulmonary disease, unspecified
Hospitalizations/Surgeries
Hospitalized for COPD exacerbation, hypoxia, influenza (12/2016) /History of hemorrhoidectomy
Family History
No family history documented
Social History
Former smoker for 10 years, retired, denies history of sexual transmitted diseases. Denies alcohol or drugs consumption.
ROS
General
Denies fatigue, weight loss or pain, insomnia, headaches, fever or changes in appetite.
Cardiovascular
Denies chest pain, admits SOB. Denies palpitations, orthopnea, weakness, weight gain.
Skin
Denies lesions, dry skin, itching, rashes, and discolorations.
Respiratory
Denies asthma, admits breathing problems, SOB. Denies blood in sputum, TB history.
Eyes
Denies blurred vision, dry eyes, , eye pain, itching, vision changes.
Gastrointestinal
Denies abdominal pain, diarrhea, constipation, and blood in stools, denies changes in appetite or bowel habits.
Ears
Denies ear pain, discharge, decreased hearing
Genitourinary/Gynecological
Denies lower abdominal pain, blood in urine, painful urination, and renal problems.
Nose/Mouth/Throat
Denies dry mouth, dentures, surgeries, decreased sense of smell, masses, difficulty swallowing, throat pain or sore, swollen glands.
Musculoskeletal
Denies pain, muscles aches, swelling joints, traumas, gout history.
Breast
Denies changes, pain, masses, or discharge.
Neurological
Denies back pain, dizziness, gait abnormalities, memory loss, seizures.
Heme/Lymph/Endo
Denies insomnia, thyroid problems, cold or heat intolerance, admits diabetes. Denies anemia, bleeding problems, swollen glands, and weakness.
Psychiatric
Denies psychiatric history, anxiety, depression, eating disorders, substance abuse and suicidal thoughts
OBJECTIVE
Weight 318 lbs BMI45.52
Temp98.2 F
BP120/84 mm/Hg
Height 70.08 in
Pulse89/min
Resp18/min
General Appearance
In no acute distress, well developed, well nourished
Skin
No suspicious lesions, warm and dry
HEENT
Head: normocephalic, atraumatic.
Eyes: pupils equal, round, reactive to light and accommodation.
Ears: normal.
Oral cavity: mucosa moist.
Throat: clear
Neck/Thyroid: neck supple, full range of motion, no cervical lymphadenopathy.
Cardiovascular
No murmurs, no gallop, regular rate and rhythm, S1, S2 normal, RRR, cardiac area in normal limit.
Respiratory
Fine crackles in the lung bases, dull to percussion to the bases.
Gastrointestinal
Abdomen soft, non-tender, no distended, bowel sounds present.
Breast
No assessed.
Genitourinary
No assessed.
Musculoskeletal
Extremities: no clubbing cyanosis, or edema.
Neurological
Non-focal, motor strength normal upper and lower extremities, sensory exam intact.
Psychiatric
AAO x3, dressed appropriately, clear speech, answers questions correctly.
Lab Tests
None
Special Tests
None
Diagnosis
Differential Diagnoses
1- J18.9 Community acquired pneumonia
2- J80 Acute respiratory distress syndrome
3- J43 Emphysema
Diagnosis
o Chronic systolic (congestive) heart failure- I50.22 (primary) (decompensate)
o Chronic obstructive pulmonary disease, unspecified- J44.9 (decompensate)
o Morbid (severe) obesity due to excess calories- E66.01
o Essential (primary) hypertension- I10
o Type 2 diabetes mellitus without complications- E11.9
o Persistent atrial fibrillation- I48.1
Plan/Therapeutics
Plan:
Chronic systolic (congestive) heart failure (decompensate):
Start furosemide tablet, 40mg, 1 tablet, orally, twice a day, 30 days, 60 tablet, refills 1
Start potassium chloride packet, 20 mEq, 1 packet with food, orally, once a day, 30 days, 30, refills 2
Chronic obstructive pulmonary disease, unspecified (decompensate)
Start azithromycin tablet, 500mg, as directed, orally, once a day, 3 days, refills 0
Morbid (severe) obesity due to excess calories
Notes: increase physical activity, low fat diet
Others
Notes: same treatment
Preventive medicine:
– Goals: control blood pressure, control hypertension through diet, control lipid levels through diet, decreased cholesterol, increase physical activity, decrease weight, decrease junk food, and promote healthy snacks.
– Education provided: adequate fluid intake, calcium needs, daily exercise, dental care, increase fruit intake, increase vegetables intake.
Follow up: 2 weeks
Evaluation of patient encounter
Strengths
• Interview
• Physical assessment
Weaknesses
• Documentation
• ICD10 codes
I will practice more to improve my skills looking for ICD10 diagnosis and documentation.
Community acquired Pneumonia symptoms include malaise, chills, rigor, fever, cough, dyspnea, and chest pain. Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates the diaphragm. (merckmanuals.com). Acute respiratory distress syndrome (ARDS) is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event, such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. (Harman, 2016). Emphysema is destruction of lung parenchyma leading to loss of elastic recoil and loss of alveolar septa and radial airway traction, which increases the tendency for airway collapse. Lung hyperinflation, airflow limitation, and air trapping follow. Airspaces enlarge and may eventually develop blebs or bullae. (merckmanuals.com). It is a classification under COPD.
According to what the patient refers, symptoms and signs, the patient doesn’t suffer of any of this disease mentioned above. However, the patient has history of COPD, Heart Problems, he refers short of breath that is worse at night since 3 days ago, and he was the whole last night sitting on the chair, in the PE I found fine crackles in the lung bases, dullness to percussion to the bases, then, I made diagnosis for CHF decompensate, because due to the heart problems, dyspnea can occur during rest and at night, sometimes causing nocturnal cough. Dyspnea occurring immediately or soon after lying flat and relieved promptly by sitting up (orthopnea). (merckmanuals.com). Also I consider the patient has COPD decompensate, because the dyspnea that is progressive, persistent, exertional, or worse during respiratory infection appears when patients are in their late 50s or 60s. (merckmanuals.com).
Regarding the obesity diagnosis, the patient BMI is 45.52. According to BMI Chart for Men & Women (2016) a BMI of less than 18.5 classifies a person as underweight; between 18.5 and 24.9 as normal; between 25 and 29.9 as overweight; 30 and 39.9 as obese and over 40 as morbidly obese.
About treatment for Chronic systolic (congestive) heart failure (decompensate), I choose furosemide, because ia a loop diuretic, that clearly improve hemodynamics and symptoms inhibiting the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle. By effectively inhibiting sodium reabsorption, they also reduce water reabsorption. The loop diuretics bind to the luminal surface of the transporter; thus, they must be secreted into the tubular lumen. (Friedman, 2015). Then, with the furosemide use, the patient loses potassium, for this reason I added potassium to the treatment to replace what the patient will loses. A low potassium level can make muscles feel weak, cramp, twitch, or even become paralyzed, and abnormal heart rhythms may develop. (merckmanuals.com)
Antibiotic therapy has been shown to have a small but important effect on clinical recovery and outcome in patients with acute exacerbations of COPD. Therefore, antibiotic administration should be considered at the beginning of treatment for exacerbations of COPD. One of the first-line antibiotics in mild to moderate exacerbations is Azithromycin (Zithromax), 500 mg initially, then 250 mg daily. (aafp.org)
Treatment of obesity starts with comprehensive lifestyle management (diet, physical activity, behavior modification), which should include the following: self-monitoring of caloric intake and physical activity, goal setting, stimulus control, nonfood rewards, relapse prevention. (Hamdy, 2017)
The others conditions will continue with the same treatment.
References
Sethi, S., MD, (n.d.). Community-Acquired Pneumonia – Pulmonary Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-pneumonia
Harman, E. M., MD, (2016, August 11). Acute Respiratory Distress Syndrome Clinical Presentation: History, Physical Examination, Complications. Retrieved from http://emedicine.medscape.com/article/165139-clinical
Wise, R. A., MD, (n.d.). Chronic Obstructive Pulmonary Disease (COPD) – Pulmonary Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-pulmonary-disease-copd
Malcolm, J., MD, (n.d.). Heart Failure – Cardiovascular Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure
BMI Chart for Men & Women: Is BMI Misleading? – BuiltLean. (2016, November 13). Retrieved from http://www.builtlean.com/2013/07/17/bmi-chart/
Friedman, E. A., MD, (2015, April 1). Diuretics and Heart Failure: Background, Technical Considerations, Outcomes. Retrieved from http://emedicine.medscape.com/article/2145340-overview
Lewis, J. L., MD, (n.d.). Hypokalemia (Low Level of Potassium in the Blood) – Hormonal and Metabolic Disorders – Merck Manuals Consumer Version. Retrieved from https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/hypokalemia-low-level-of-potassium-in-the-blood
Hunter, M. H., MD, (n.d.). COPD: Management of Acute Exacerbations and Chronic Stable Disease – American Family Physician. Retrieved from http://www.aafp.org/afp/2001/0815/p603.html
Hamdy, O., MD, (2017, March 2). Obesity Treatment & Management: Approach Considerations, Patient Screening, Assessment, and Expectations, Weight-Loss Goals. Retrieved from http://emedicine.medscape.com/article/123702-treatment