SOAP NOTE: Chronic Obstructive Pulmonary Disease

SOAP NOTE: Chronic Obstructive Pulmonary Disease

 

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Name:   K. B  Pt. Encounter Number: 315/2018
Date:  01/05/2018 Age:  76 Sex:  Female
SUBJECTIVE
CC: 

“I have experienced difficulty in breathing, cough that is continuously increasing, sputum production as well as instances of wheezing during exhalation and inhalation. There is also chest pain”

 

HPI: 

The patient illustrated that three months ago, such symptoms existed which prompted hospitalization and was treated and discharged…

Medications:

Due to chest pain as well as headaches, the patient has been taking ibuprofen 400mg three times in a day.

PMH

Allergies:   No known food or drug allergies.

Medication Intolerances: None.

Chronic Illnesses/Major traumas : None

 

Hospitalizations/Surgeries

  The patient had been hospitalized twice. The two admissions occurred in June 2015 and February 2017 and were due to bronchitis both of which were treated successfully. There is no history of surgery.

Family History

Her mother died of hypertensive heart disease while the father died in a tragic road accident…

Social History

The patient is a retired don having taught in a nursing school for many years…

ROS
General

The patient reports reduced energy with no marked change in weight.

Cardiovascular

She reports presence of chest pain that is intense when coughing. No palpitations or edema.

 

Skin

There is good skin turgor. The skin is wrinkled. No visible lesions, bruises or rashes.

Respiratory

She reported coughs and wheezing which had lasted three days. There also existed difficulty in breathing and shortness of breath. No history of tuberculosis.

Eyes

No reports of use of corrective lenses or experience of blurred vision.

Gastrointestinal

No instance of constipation, abdominal pain, hemorrhoids, diarrhea, nausea and vomiting.

Ears

No discharge or pain reported from the ear.

 

 

Genitourinary/Gynecological

Patient denied presence of any urinary symptom. Patient in menopause, no vaginal discharge, less sexual activity.

 

 

Nose/Mouth/Throat

The patient denied swollen or bleeding gums. She had no hoarseness of voice. No discharge from the nose.

Musculoskeletal

She denied presence of muscle pain. No stiffness of joints. No history of fracture.

Breast

She knows and conducted self-breast examinations. No lumbs on the breasts.

Neurological

She reported instances of headache that had been on and off for the last two days. No history of seizures.

Heme/Lymph/Endo

She is HIV negative based on the test that was done in February 2018. Has no history of blood transfusion or even donation. No swollen lymph nodes.

Psychiatric

The patient denied episodes of anxiety, suicidal ideations or difficulty in maintaining sleep.

OBJECTIVE
Weight  :   69   BMI Temp  : 98 BP  : 115/78
Height  : 5.7’’ Pulse  : 76 Resp  : 20
General Appearance

A healthy looking female geriatric with no distress or display of low energy…

Skin

She has clean, warm and intact skin. No rashes, bruises or lesions.

HEENT

Head is normocephalic. ….

Cardiovascular

On auscultation, the S1 and S2 are heard. Regular heart rhythm and rate. No facial edema. Capillary refill of 2 seconds.

Respiratory

There is labored and noisy breathing. The wheezing can be heard both during inspiration and exhalation.

Gastrointestinal

No distention in the abdomen. Bowel sounds can be heard from all the quadrants.

Breast

No lumbs on the breast.

Genitourinary

The system was not explored due to request from the client but reported no alarming issue from the same.

 

Musculoskeletal

During the entire period of assessment, full range of motion is observed from the four extremities.

Neurological

The speech is clear. She has a normal gait with stable balance.

Psychiatric

Patient is fully oriented. She is well groomed and maintains eye contact throughout. She responds to questions appropriately.

Lab Tests
Arterial blood gas analysis- is pending
Special Tests

Chest X-ray– pending

Spirometry- FEV1=78% AND FEV1/FVVC=0.5

 Diagnosis
Chronic Obstructive Pulmonary Disease.

Refers to inflammatory disease of the lung and obstructs airflow. It manifests in the form of difficulty in breathing, wheezing and sputum production. According to Sam et al., (2017), the condition originates from exposure to irritants…

Lung Cancer.

 

Pneumonia.

 

Final Diagnosis   

 

PLAN

Further testing

 

Medication

Education

Follow-up

References

Kanai, O., Fujita, K., Okamura, M., Nakatani, K., & Mio, T. (2016). Severe exacerbation or

manifestation of primary disease related to nivolumab in non-small-cell lung cancer

patients with poor performance status or brain metastases. Annals of Oncology27(7),

1354-1356.

Ohberg, F., Wadell, K., Blomberg, A., Claesson, K., Edstrom, U., & Holmner, A. (2016). Home-

Based System for Recording Pulmonary Function and Disease-Related Symptoms in

Patients with Chronic Obstructive Pulmonary Disease, COPD-A Pilot Study. SM J Pulm

            Med2(1), 1011.

Sama, S. R., Kriebel, D., Gore, R. J., DeVries, R., & Rosiello, R. (2017). Environmental

triggers of COPD symptoms: a case cross-over study. BMJ open respiratory

      research4(1), e000179.

 

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