SOAP NOTE

Allergies: No known food or drug allergies.

Medication Intolerances:None.

Chronic Illnesses/Major traumasNone.

Hospitalizations/Surgeries

The patient reports that he has been admitted twice in hospital. The two admissions occurred in July 2015 and March 2017 respectively both due to bronchitis which was treated and he recovered. No history of surgery.

Mother died of hypertension while the father succumbed to injuries from a road accident. Has a sister who is 77 years old and is suffering from osteoarthritis. The wife is 64 and is having diabetes mellitus. He has two daughters with no medical history.

The patient retired as a lecturer in a university having specialized in business management. The wife is business lady. They stays together in an apartment with his wife and the house help. He smokes cigarettes and has been using it for the last 18 years.  He uses 6 rolls per day. Both the patient and the family members observes safety measures while using cars and playing games.

The patient reported reduced energy without a significant change in weight.

He reported episodes of chest pains especially while coughing. No edema or palpitations.

The skin is wrinkled with good skin turgor. No reports of bruises, rashes or lesions.

Reports coughs and wheezing which has persisted for the last for the last four days. He had also been experiencing shortness of breath and difficulty in breathing. No history of tuberculosis in the patient.

No reports of blurred vision or use of corrective lenses.

The patient denied instances of abdominal pain, constipation, diarrhea, hemorrhoids, nauseas and vomiting.

No pain or discharge reported.

No urinary symptoms. Had been tested for PSA using the rapid test which turned negative in October 2017.

Denied swollen or bleeding gums. No dysphagia or hoarseness of voice. Reported no discharge from the nose.

No muscle pain. No history of fracture, pain or stiffness of joint.

No lumbs on the breast area.

Reported episodes of headaches which are on and off for the last two days. No history of seizures.

He is HIV negative as per the previous test in July 2017. No history of blood donation or transfusion. No swollen glands.

Denied instances of anxiousness, difficulty in sleeping or suicidal ideations.

Health appearing elderly male patient in no distress or low energy. He is alert and well groomed. Has communicate well throughout the assessment period.

Patient has an intact skin that is clean and warm. No rashes, lesions or bruises noted.

Head: Normocephalic. Eyes: No discharge, the pupils are equal and reacts to light. Ears: the patient is able to hear well, the canals are patent and normal pinna. The tympanic membrane are gray. No discharge was observed during otoscopy. Nose: mild nasal flaring. Neck: Full range of motion. No swollen lymphnodes. All the teeth are present with no bleeding gum. No halitosis.

S1 and S2 are heard. Heart rhythm and rate are regular. No edema on the face or the extremities. The capillary refill time is 2 seconds.

Labored breathing. Symmetrical chest wall. Wheezing heard from patient on both inhalation and exhalation.

No obvious organomegaly or distension in the abdomen. Bowel sounds active in all four quadrants.

No lumbs on the breast area. No wrinkling or discoloration of the skin.

Not explored.

Full range of motion is seen on all the four extremities during the period of assessment. No fractures.

He has a stable balance and normal gait. The speech is clear.

The patient is oriented to time, place and person. He is well groomed and maintains eye contact while expressing himself. He answers the questions appropriately.

Spirometry- FEV1=77% and FEV1/FVC=0.5

Chest X-ray- pending.

It is an inflammatory disease affecting the lungs. It causes obstructed airflow from the lungs. This leads to the manifestation of difficulty in breathing, cough with sputum production as well as wheezing. It is attributed to persisted exposure to irritants such as dust, irritating gases and particulate matter such as smoke from a cigarette (Sama et al., 2017). It leads to impaired aeration to the lungs hence reducing the oxygen content in the blood with an accumulation of carbon dioxide.

Lung Cancer.

This cancer starts primarily in the lungs. Occurs when the carcinogenic materials lead to abnormal mutation of cells in the lungs to cause inflammation and rapid growth of calls in the lung. The lung cancer destroys the normal lung cells and impairs the lung functions. It may not manifest in the early stages until its advancement. In the advanced stages, it may present with pain that is persistent(Kanai et al., 2016). The patient may experience breathlessness and cyanosis.

Pneumonia.

The patient presents with a cough and rusty sputum production. The patient will also have tachycardia, chest pain, and difficulty in breathing, nausea, and vomiting as well as shortness of breath.

Final diagnosis

Chronic Obstructive Pulmonary disease is the final diagnosis based on the presentation of T.M. He presented with cough, sputum production as well as difficulty in breathing. The patient is also a chronic smoker which is a vital risk factor for COPD. The patient also reports a history of the symptoms with early admissions. This indicates the insidious nature of the condition. Spirometry also shows the obstruction of the airways hence classical to COPD. Differentiation of COPD and lung cancer can further be differentiated via computed tomography.

PLAN including education

o     Plan:  

    Further testing

Computed Tomography of the lungs

    Medication

Ibuprofen 400mg three times a day to reduce inflammation of the airway.

Ipratropium nebulizer inhalation solution 500mcg is taken four times a day.

    Education

Will be focused on advising the client to quit smoking which is the irritant and causative factor for the condition. The patient will also be advised on adherence and compliance to medication.

    Follow-up

The patient will be reviewed with X-ray, CT scan and arterial blood gas analysis on the third day for the determination of response to medication as well as for further management.