SOAP note Case Analysis

Pneumonia

Soap Note with case analysis. Include the patient info provided in the attachments. More patient info – Patient was seen in a primary care setting by a nurse practitioner. Hispanic, 37 years old. She reported dry cough that worsened when lying down, non-productive. No fever, no other symptoms. Went to the doctor for clearance for a tooth extraction.

She reported an MI last June but there is no record of hospitalization, so it can be reported as a \”cardiac event\”. According to her the cardiologist only prescribed enalapril and aspirin. She is not taking any other medications. She has 2 children. Her sister is asthmatic. She denies allergies or any diagnosed chronic condition. Patient is obese.

 

Case Analysis SOAP GRADING RUBRIC

Guidelines:

1-Choose a client from your clinical setting & write up a case analysis (see below for content).

2- SOAP note from your clinical should be included (remove all patient identifiers)

5- Each SOAP is 5% of your total grade; attach grading rubric to each paper submitted.

SUBJECTIVE Analysis (1 POINT)	Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria; a-Identified and collected the necessary data b-Categorized and organized data using the appropriate format c-Incorporated all pertinent data/facts d- Used proper documentation e- PATIENT’S CULTURE MUST BE NOTED
OBJECTIVE Analysis (1 POINT)	Score received
1- Compare & contrast objective section with literature taking into consideration the following criteria a. Identified and collected the necessary data b. Categorized and organized data using the appropriate format c.Incorporated all pertinent data/facts d. Used proper documentation
ASSESSMENTAnalysis (1 POINT)	Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria a-Filtered relevant data from irrelevant data b.-Interpreted relationships/patterns among data (e.g., noted trends) c.Integrated information to arrive at diagnosis d.Identified risk factors e.  Differentials listed & discussed in comparison to actual diagnosis e. Used proper documentation
PLAN Analysis (1 POINT)	Score received
1- Compare & contrast subjective section with literature taking into consideration the following criteria a. Recommended an appropriate plan for each problem b-Included recommendations for non-drug and drug therapy c-Included recommendations for monitoring d- Included health education e- Included followup& referrals f- include cultural considerations of patient care Incorporate the patient’s culture on the demographic section on  SOAP notes.  Additionally, in the intervention section the student should add a piece about how they had to be “culturally sensitive” towards the patient or if they performed any culturally specific interventions.
FORMAT ( 1 POINT)	Score received
1- APA 2- References Current 3- Writing clear, concise 4- Summary/Conclusion
TOTAL

Solution

 

SOAP Note with Case Analysis

Student’s Name

Institutional Affiliations

 

SOAP Note with Case Analysis

 

SOAP Note

Patient Initials: J.K.                Age: 37 years old           Race: Hispanic              Gender: Female

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “I have a cough.”

History of Present Illness (HPI): J.K. is a 37-year-old Hispanic female who has visited the clinic for a medical check-up after developing a cough. She has reported a dry cough that worsened when lying down. The cough is non-productive. Patient J.K. lastly saw a doctor for a tooth extraction. She reported an MI last June but there is no record of hospitalization, so it can be reported as a ‘cardiac event’. During her last visit to the hospital, the patient’s the cardiologist only prescribed enalapril and aspirin.

PMHx: J.K. is obese but she denies any diagnosis with other chronic conditions. She reported an MI last June but there is no record of hospitalization.

Past Surgical Hx: Denies surgical history.

Social Hx: J.K. is not employed at the moment. She is happily married and sexually active. Denies smoking, alcohol consumption, and the use of illicit drugs such as cocaine and heroin. According to J.K., she is physically active and usually performs activities of daily living on her own. She hardly engages in exercise activities outside the house.

Medications:

• Enalapril 1X day
• Aspirin 1X day
• COVID vaccinated
• Amoxicillin prophylactic for a tooth extraction

Sexual/Reproductive History: J.K. has 2 children. She had her children through a normal delivery. Denies reproductive issues.

Significant Family History: J.K.’ sister is asthmatic. Her parents are still alive. The father was diagnosed with hypertension two months ago. Her two children are healthy.

Immunization History: J.K. reports receiving all her immunizations as required.

Allergies: Denies drug and food allergies.

 

Review of Systems (ROS):

 

General: No fever, no other symptoms.

HEENT:

Head: Denies physical head injury. Does not report a mild headache.

Eyes: Denies changes in vision. Visual acuity is good. Conjunctiva is moist and pink. The sclera is white.

Ears: No hearing problems reported. Denies ear pain.

Nose: Denies nasal congestion. No runny nose reported. Denies pain in the nose.

Throat: Reports a dry cough, non-productive but worsens when lying down.

Neck: Does not report neck-related pain reported.

Respiratory: Denies tightness of the chest. Reports breathing difficulties. Denies having pain on the chest.

Cardiovascular/Peripheral Vascular: Denies chest tightness.

Gastrointestinal: No stomachache, no constipation, no abdominal pain.

Genitourinary: Does not report pain in the genitals. No vaginal itching. No pain during urination. Denies abnormal vaginal discharge. Does not report abnormal urination frequency.

Musculoskeletal: Does not report joint pain. No overall body weakness.

Neurologic: Denies headache. Does not report numbness on fingers and toes.

Psychiatric: Denies occasional seizures, issues with memory, vision changes, or feelings of hopelessness.

Skin: Denies itchiness or redness on the skin. No skin rashes reported.

Hematologic: Does not report anemia or any other blood-related disorders.

Endocrine: No excessive thirst, no frequent urination. Denies an abnormal increase in urine volume. No weakness, no abnormal sweating at night.

 

OBJECTIVE DATA:

 

Physical Exam:

Vital signs:

Height: 48.6 inches; Weight: 127 lb; RR: 18; HR: 82; BP: 130/80; Oxygen saturation: 99%; Temperature: 36 degrees Celsius.

General Appearance: J.K. is attentive and neatly dressed. She can describe her symptoms and is able to respond to questions properly. She does not appear mentally distressed.

HEENT:

Head: Head is Normocephalic with no evidence of trauma. Hair is evenly distributed throughout the scalp. No masses observed on the scalp. No tenderness of the frontal and maxillary sinuses. No lymphadenopathy observed.

Eyes: Eyes lashes and eyebrows are intact. The eye lids are without lesions, no edema on both eyes. White sclera observed, pink conjunctiva with no lesions. The pupil is centrally positioned. They are sensitive to changes in light stimuli. The fundus has no hemorrhage. Visual acuity is at 20/20. The patient does not use corrective lenses.

Ear: A pearly-grey color observed on both tympanic membranes. Both tympanic membranes are intact. The pinna are positioned symmetrically on both sides of the head. No evidence of blockage in the ear canal. Both ears are responsive to sound stimuli.

Nose: The nasal mucosa is moist and pink. It is also hairy and without lesions. The septum is positioned midline. No nasal discharge.

Throat/Mouth: No mouth ulcers observed. No erythema on the throat.

Neck: No swelling observed. No pain and the skin around the neck is clear. The strength of neck muscles: 5/5.

Cardiovascular: No edema is observed in the legs. No heart murmur. No gallop. No bruit in the arteries. It takes less than 3 seconds for a complete capillary refill to occur.

Chest/Lungs: The patient displays/expresses difficulty during lung contract and relaxation during exhalation and inhalation respectively. Chest walls are without deformity and lesions. Adventitious sounds, specifically wheezing is heard on the chest.

Abdomen: No distention or masses. Absence of abdominal tenderness. Absence of lesions. Dullness is absent on the spleen on percussion.

Genitourinary: No warts or swellings observed. No evidence of abnormal vaginal discharge.

Musculoskeletal: No evidence of joint pain on touching. Nails are without ridges. Absence of abnormal gait. Has a normal balance.

Neurological: Absence of coordination issues. Both lower and upper limbs are sensitive to pain stimulus.

Skin: The skin is hairy, warm, moist, and without rashes. Skin turgor or elasticity is good.

Psychological: No signs of depression or anxiety.

Lab tests and other procedures:

• CBC test: Elevated neutrophils and white blood cells.
• Glucose challenge test (GCT): 7.6 mmol/L. This indicates the presence of diabetes mellitus.
• Blood tests: Cholesterol and triglyceride levels are evidently high. This indicates hyperlipidemia.
• Urinalysis: Protein detected in urine. Proteinuria is an evidence of impaired lipid metabolism. This confirms hyperlipidemia.

 

ASSESSMENT:

 

Differential diagnoses:

1. Pneumonia (Primary diagnosis).
2. Acute Bronchitis
3. Chronic Obstructive Pulmonary Disease

Rationale

1. Pneumonia (Primary Diagnosis)

The pathophysiology of pneumonia is associated with the inflammation of lung parenchyma cells. The inflammation is usually triggered by an imbalance in the concentrations of microorganisms of the lower respiratory tract (Kaysin & Viera, 2016).  An imbalance in these microorganisms triggers an increased production of macrophages which eventually stimulate the secretion of cytokine such as interleukin-1 and interleukin-8.

The presence of these cytokines triggers the secretion of other inflammatory cells such as neutrophils whose action lead to the inflammation of the parenchyma cells of the lungs. A recent travel is a risk factor for community-acquired pneumonia. A cough with or without sputum is a common symptoms of pneumonia. The cough in pneumonia worsens at night, especially when a person is lying down (Kaysin & Viera, 2016). Other symptoms include shortness of breath, difficulty breathing, and wheezing sound. Patient J.K. reports a dry cough, non-productive, which worsens when she is lying down. These symptoms suit pneumonia as her primary diagnosis. The presence of pneumonia is further confirmed by an elevation on neutrophils and white blood cells.

2. Acute Bronchitis

Acute bronchitis is a respiratory disease like pneumonia that is commonly diagnosed among adults. The pathophysiology of acute bronchitis entails the inflammation of bronchi. This causes thickening of the bronchial mucosa which makes affected persons present with difficulty breathing. Symptoms associated with bronchitis include coughing, wheezing, and breathing difficulty. However, the cough in acute bronchitis is normally productive (Singh et al., 2021). Patient J.K. complains of a dry cough that worsens with lying down. Therefore, acute bronchitis is less likely.

 

1. Chronic Obstructive Pulmonary Disease (COPD)

COPD is a respiratory disease just like pneumonia and bronchitis. The pathophysiology of COPD involves damage of tiny air sacs of the lungs. The damage may be caused by bacteria or by smoke from cigarettes. Affected persons normally present with difficulty breathing due to an impairment in gaseous exchange. Shortness of breath that becomes severe with activity and resolves during rest is a common symptom of COPD.

Besides, persons with the disease usually present with persistent cough (American Academy of Family Physicians, 2017). However, the cough is normally productive and is characterized by the production of whitish-yellow sputum. Patient J.K. is a non-smoker and does not produce sputum when coughing. These factors rule out the presence of COPD.

 

PLAN:

 

Diagnostics/Labs/Imaging

• A complete blood count (CBC) test: This is performed to assess the concentrations of different types of blood cells. Results have revealed elevated neutrophils and white blood cells (WBC). Similar results are normally observed in bronchitis and pneumonia.
• Chest x-ray: Infiltrates or white spots observed. This indicates the presence of pneumonia
• ECG: Nonspecific ST-segments observed. Pneumonia confirmed.
• Conduct a sleep apnea study.

Therapeutics:

Medications:

• Prescribe Zithromax (Z-PAK)
• Albuterol taken twice daily
• Metformin 500 mg twice daily
• Atorvastatin 20 mg

Non-drug therapy:

• The patient was advised to always keep warm and drink warm water to prevent pneumonia from worsening (Edelman et al., 2017).
• She was advised to eat a balanced diet and engage in exercise for speedy improvement in disease symptoms.

Patient education:

• The patient was educated about the causes of pneumonia and how to avoid risk factors. Additional education focused on the signs and symptoms that the patient should watch out on and guidance offered on how to report to the clinic whenever they occur (Dains et al., 2016).
• Patient J.K. was educated about the importance of adhering to the prescribed medications. She was further informed about the possibility of drug resistance which can be prevented through medication compliance (Kaysin & Viera, 2016).
• The patient was educated on how to manage her symptoms at home (Edelman et al., 2017).

Referrals:

• Referred to a cardiologist for heart function assessment.
• Referred to a pulmonologist for lung function assessment (Ball et al., 2017).

Follow-up/Return: The healthcare provider has advised the patient to return to the clinic for evaluation after 1 month

 

SOAP Analysis

 

Subjective Analysis

The subjective portion of the note has provided a summary of the assessment information as reported by the patient. The section contains necessary data that the nurse has collected during subjective assessment. Sullivan (2019) recommends that the subjective assessment begins by stating the patient’s chief complaint following by a documentation of the patient’s illness before describing medication history, allergies, past medical history, social history, surgical history, reproductive history, significant family history, immunization history, and a comprehensive review of systems.

The clinician has followed these guidelines when developing the subjective portion of the note. The section has included all pertinent data facts that the clinician requires to make an accurate diagnosis and recommend a culturally-appropriate and age-appropriate treatment. From the subjective data, it is evident that patient J.K. is 37 years old. She is of Hispanic origin. Her reason for visiting the clinic today is that she has a dry cough that is non-productive but worsens when she is lying down. This information has guided objective documentation, assessment, and planning.

Objective Analysis

Objective portion of the note incorporates information on results obtained by the clinician after directly observing the patient and conducting necessary tests. Subjective evaluation is highly crucial during patient assessment because it helps the clinician to determine whether the symptoms reported by the patient during subjective evaluation are caused by changes in the functioning of various body organs and systems (Dains et al., 2016; Ball et al., 2017).

Proper documentation of this areas has been done and the clinician has collect relevant facts. Information that is pertinent for making a diagnosis that has been captured in this area include; difficulty breathing, a wheezing sound, and positive laboratory findings namely elevated neutrophils and white blood cells after conducting the complete blood count (CBC) test.

Assessment Analysis

The assessment section documents the illness/ diagnosis of the patient. The primary illness or diagnosis that is appropriate for the patient based on the subjective and objective data is pneumonia. Pneumonia can be diagnosed in people of different ages and gender (Kaysin & Viera, 2016). Patient J.K. is a female aged 37 years and she is not protected from catching pneumonia. Both subjective and objective information support pneumonia diagnosis. The appropriate differential diagnoses based on the patient’s symptoms are acute bronchitis and chronic obstructive pulmonary disease (COPD).

Plan Analysis

The plan section describes the additional diagnostic tests that have been conducted to rule out the presence of acute bronchitis and COPD. Additional information in this area includes the prescribed medications, non-pharmacological interventions recommended, patient education, referrals, and follow-up. The recommended treatment is meant to address individual health issues identified during laboratory testing including those that are not linked with the chief complaint. From the laboratory test findings, it is evident that the patient has multiple conditions including pneumonia, diabetes mellitus, and hyperlipidemia. The choice of medications has been guided by documented clinical practice guidelines (Kaysin & Viera, 2016).

Drug choice has incorporated relevant pharmacodynamic factors including the patient’s age and gender. Essentially, the drug dosages have been chosen to enhance their efficacy and minimize side effects. The recommended treatment has followed clinical practice guidelines. For instance, metformin 500 mg is an evidence-based medication for treating diabetes mellitus and atorvastatin is recommended for managing hyperlipidemia. Besides, albuterol and Z-Pack are evidence-based interventions for respiratory symptoms such as a cough and wheezing that often occur in persons with pneumonia (Kaysin & Viera, 2016).

An important lesson learned from this case is that a patient might have other health conditions that are not aligned with the chief complaint. Therefore, it is important to conduct numerous medical tests to identify all possible health problems that a patient might be suffering from (Dains et al., 2016). The assessment process and treatment plan has taken the patient’s culture into consideration.

Being of a Hispanic origin, patient J.K. might have had challenges expressing herself and accepting the recommended treatment (Edelman et al., 2017). To strengthen the patient-provider relationship, the clinician remained culturally sensitive during communication by using a simple language to enhance understanding. Moreover, the clinician has chosen only those treatments that the patient is comfortable with.

 

References

American Academy of Family Physicians. (2017). Chronic Obstructive Pulmonary Disease: Diagnosis and Management. American Family Physician, 95(7):433-441. https://www.aafp.org/afp/2017/0401/p433.html

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Edelman, C., Mandle, C., & Kudzma, E. (2017). Health promotion throughout the life span. 9^th ed. Elsevier Health Sciences. ISBN: 0323416748, 9780323416740.

Kaysin, A., & Viera, A. (2016). Community-acquired pneumonia in adults: Diagnosis and management. American Family Physician, 94(9), 698-706. https://www.aafp.org/afp/2016/1101/p698.html

Singh, A., Avula, A, & Zahn, E. (2021). Acute bronchitis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia