INFECTIOUS PNEUMONIA
Instructions
This SOAP note:
Chief Complaint: 2 year old female comes in with mom with fever and productive cough for a week.
Definite diagnosis: INFECTIOUS PNEUMONIA
Differential diagnosis:
- Infectious Pneumonia
- Bronchiolitis
- Foreign Body Aspiration
SOAP Note Cheat Sheet
| Required Documentation | Comments |
| Chief Complaint (In the patient’s own words with quotations) | |
| History of Present Illness (HPI) | |
| Past Medical History (PMH) – including vaccinations with number in series | |
| Allergies (Medication, Food, Environmental) | |
| Medications, dosages, and Indications (including herbals, supplements, and OTCs) | |
| Family History (FH) | |
| Social History (SH) | |
| Review of Systems (ROS)
(CV, Respiratory and others relevant to focused visit) |
|
| Physical Examination
(CV, Respiratory and others relevant to focused visit) |
|
| Lab Results (most recent results) – specifically note abnormal results in an easily identifiable fashion | |
| Differential Diagnoses (at least 3 that includes your final diagnosis) – WITH short evidence-based explanation of how they were determined and how they apply to this patient specifically | |
| Definitive Diagnosis (Final) – AND explain how this was determined using an evidence-based explanation | |
| Plan – This should be exhaustive, patient-centered, and based on current evidence-based practice. Include medications prescribed with dosages and instructions, diagnostic(s) recommended, any referrals made, and follow-up plan. Remember-Health Promotion/Health Education – should be patient-centered and based on evidence-based practice | |
| References in APA Format |
Instructions: Follow the rubric above to develop your SOAP notes for this semester. The focus is on your growing ability to integrate your subjective and objective information gathering into the formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages.
You are required to provide a list of differential diagnoses (at least 3) with evidence-based explanations of “why” they fit your patient’s illness scenario and “how” you determined the final diagnosis. You will be adding in the management portion within your “plan” which may include prescribing, diagnostics, and/or complementary therapies and will include health promotion and health education.
Solution
SOAP Note
Patient Initials: F.R. Age: 2 years Gender: Female Race: White
Subjective
Chief Complaint (CC): “My daughter has fever and productive cough.”
History of Present Illness (HPI): A 2-year-old female client has come to the clinic with her mother. The mother has reported that her daughter has fever and productive cough. These symptoms have lasted for a week.
Past Medical History (PMH): The patient was admitted once due to pneumonia-related complications when she was 8 months old. She has not had any other hospitalizations since then. However, she occasionally develops fever which is effectively controlled using pain-relieving syrup.
Immunization: The client has been receiving her immunizations as scheduled. The diseases for which the client has been vaccinated include; measles, mumps, rubella, influenza, hepatitis B, rotavirus, influenza, and varicella in their correct doses.
Allergies: No known drug or food allergies
Medications: Paracetamol syrup given to relieve the fever.
Past Surgical History (PSH): The client has not undergone any surgery before.
Family History: The client’s father was diagnosed with diabetes 2 years ago. Her mother is on medications to manage her hypertension. Her maternal grandmother died from pneumonia while her maternal grandfather is currently healthy without any negative diagnoses. The client’s older siblings are healthy without any significant medical conditions.
Social History: As reported by her mother, F. R. is the third born in a family of three children. Both her parents are alive. The patient is always active and displays characteristics that are common to children her age. The patient’s current illness has negatively affected her social behavior as she no longer plays a lot like she normally do when healthy. F.R. usually remains at home under the care of a house manager when her parents have gone to work.
Review of Systems:
General: No significant changes in weight noticed, there are no chills. F. R. has fever and a productive cough.
HEENT: The patient’s mother denies injury on her head. The child’s presentation does not show evidence of ear and eye issues. nose, and throat is
Skin: No rashes on the skin.
Respiratory: There is a productive cough. The mother has not noticed any signs of shortness of breath.
Cardiovascular: No signs of chest pain and chest congestions have been noticed by the client’s mother.
Gastrointestinal: The client’s mother denies nausea/vomiting, diarrhea, or constipation.
Musculoskeletal: The client has a normal gait. No falls reported.
Neurologic: No headaches, no dizziness reported.
Objective
Vital Signs: Heart rate=90 bpm, respiratory rate=18, blood pressure=90/60 mm Hg, temperature, 97.9 F, healthy weight (5th percentile).
General: Patient F. R. is well-dressed for the weather. She is attentive and maintains an eye contact. She appears dull, fatigued, and distressed.
HEENT: The head is normocephalic with no evidence of injury and no scalp lesions, the tympanic membrane in the ears is clear. The client’s eyes are sensitive to light. Nasal mucosa is pink, moist, and hairy. The throat is not clear and is non-erythematous.
Skin: Smooth, warm, and without rashes.
Chest/Lungs: The lungs are correctly positioned on the left and right sides of the chest. There is a productive cough and wheezing. Evidence of shortness of breath. Crackles are heard in the chest during observation. Breath sounds are lacking in some regions of the chest.
Cardiovascular Peripheral/Vascular: Relatively faster heart rate, no murmurs, no gallops or bruits auscultation. Peripheral pulses are present.
Musculoskeletal: Muscle stiffness and mild joint pain.
Laboratory tests: Sputum culture; urinary antigen test to detect Streptococcus pneumoniae and Legionella pneumophila; PCR to identify the associated organism; Gram staining; complete blood count.
Assessment:
Definite diagnosis: Infectious pneumonia
Differential diagnoses:
- Infectious Pneumonia
- Bronchiolitis
- Foreign Body Aspiration
Rationale
Infectious Pneumonia
Infectious pneumonia is the most likely diagnosis for patient F. R. Patients often acquire infectious pneumonia from the community. The species of bacteria that cause pneumonia include; Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Children aged 5 years and below are at an increased risk of developing infectious pneumonia. The organism involved affects the tissues and organs of the lower respiratory tract leading causing clinical conditions that appear as disease symptoms. For example, a wheezing sound and crackles in patients with pneumonia are associated with fluid accumulation in the lungs.
The presence of fluid interferes with the flow of gases and this explains why breath sounds are lacking in some regions of the chest (Sattar & Sharma, 2021). Chest congestion, fever, and productive cough are common symptoms of infectious pneumonia in children. Chest congestion and a productive cough are attributed to the pathophysiology of the disease. The bacterial activity causes the lung alveoli to produce serious exudates. It also results in the overproduction of neutrophils and macrophages (Sattar & Sharma, 2021). Shortness of breath and a productive cough accompanied by fever occur in the affected children. Affected children may also have swollen joints causing difficulty in movement.
Bronchiolitis
Bronchiolitis is a possible diagnosis for patient F. R. It is a respiratory disease that occurs following the inflammation of the epithelial cells in the bronchioles. Cellular necrosis and mucus production occur. These substances obstruct the airway causing wheezing. Clinical manifestations of bronchiolitis include; nasal congestion, runny nose, a cough that lasts for about three days, and decreased appetite (Erickson et al., 2021). While some of these symptoms are present in patient F. R., some of them are absent.
Foreign Body Aspiration
The presence of foreign bodies in the airway can cause respiratory issues that resemble those of pneumonia. Foreign body aspiration is a common respiratory issue in pediatrics. Foreign bodies usually obstruct the airways leading to difficulties in breathing. They may also trigger physiological responses such as mucus production. The mucus clogs the throat which makes the affected children present with a productive cough. Notably, fever rarely occurs in children with foreign body aspiration (Cramer et al., 2020). Since patient F.R. has a fever, the likelihood that she is foreign body aspiration is quite minimal.
Plan
Diagnostics
The healthcare professional can perform numerous diagnoses to confirm the presence of infectious pneumonia. The laboratory tests that can be conducted include; Sputum culture; urinary antigen test; PCR to identify the associated organism; Gram staining; complete blood count. A sputum culture will help the healthcare provider to identify the bacterial growth and establish the specific type of disease-causing organism (Torres et al., 2016).
A urinary antigen test, PCR, and gram staining should be conducted to detect Streptococcus pneumoniae and Legionella pneumophila. The blood concentration of neutrophils and macrophages is normally elevated in patients with infectious pneumonia. These changes in concentration can be confirmed by conducting a complete blood count (CBC) (Torres et al., 2016). It is also important to perform a pulmonary function test to assess how well the lungs are functioning (Ponce & Sharma, 2018).
Medications
Infectious pneumonia is usually treated using antibiotics. The type of antibiotic and dose to be administered is usually chosen based on the type of disease-causing organism identified during laboratory testing. The first choice treatments for infectious pneumonia are azithromycin and clarithromycin (Pahal et al., 2021). F. R can be managed as an outpatient. The patient must adhere to the prescribed regimen to realize positive health outcomes.
Patient Education
Patient education is highly crucial in the current scenario because it is a good way of informing the patient’s mother about the best practices and behaviors that will generate positive health outcomes. The patient’s mother must be taught about the importance of medication compliance (Sattar, A., & Sharma, 2021). She should also be informed to report to the clinic in case the patient suffers serious reactions during drug use.
Health Promotion
Effective care of patient F.R. requires the involvement of an interdisciplinary team. As part of health promotion, the patient’s mother should be encouraged to practice 30 minutes to one-hour walk daily with her daughter. She should also ensure that the patient eats a balanced diet until the symptoms disappear (Pahal et al., 2021). Furthermore, a routine respiratory check will help in ensuring that the patient does not develop serious respiratory issues in the future.
Disease Prevention
The patient is required to keep warm, eat a balanced diet, and maintain good hygiene to prevent pneumonia from reoccurring. The patient’s mother should be advised to monitor her daughter closely to identify issues/factors that may increase her risk of developing pneumonia. She should avoid dusty places and any other irritants that may cause disease (Pahal et al., 2021).
Follow Up Care
The healthcare professional should develop a good follow-up plan to assess how F. R. is responding to medications. Patient follow-up will also enable the healthcare provider to address the patient’s concerns (Sattar, A., & Sharma, 2021). Any issues that might arise during follow-up should be used to improve the treatment and management plan.
References
Cramer, N., Jabbour, N., Tavarez, M. M., & Taylor, R. (2020). Foreign body aspiration. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531480/
Erickson, E. N., Bhakta, R. T., & Mendez, M. D. (2021). Pediatric bronchiolitis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519506/
Pahal, P., Rajasurya, V., & Sharma, S. (2021). Typical bacterial pneumonia. [Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534295/
Ponce, M., & Sharma, S. (2018). Pulmonary function tests. Treasure Island (FL): StatPearls Publishing
Sattar, A., & Sharma, S. (2021). Bacterial pneumonia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513321/
Torres, A., Lee, N., Cilloniz, C., Vila, J., & Eerden, M. (2016). Laboratory diagnosis of pneumonia in the molecular age. European Respiratory Journal, 48, 1764-1778; doi:10.1183/13993003.01144-2016