Week 3 reply

Garry

Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.

 

SOAP Note

 

Demographics: 56-year-old female

Subjective

Chief Complaint (CC): Persistent cold with a dry cough, muscle aches, headache, shivering, and fatigue for several weeks.

History of Present Illness (HPI):

· Duration: Several weeks

· Quality: Dry, jacking cough; muscle aches; headache

· Associated symptoms: Shivering despite hot weather, fatigue

· Aggravating factors: None specified

· Alleviating factors: None effective, over-the-counter medications tried with no effect effect

· additional information: patient states that the symptoms have persisted despite various treatments.

Questions related to CC:

· Have you experienced any shortness of breath or difficulty breathing?

· Have you had any chest pain?

· Do you have any history of respiratory illness or conditions such as asthma or COPD?

· Have you noticed any palpitations or irregular heartbeats?

· Any swelling in your legs or ankles?

· Have you had any dizziness or light-headedness?

· Any change in vision or speech?

· Have you had any recent weight loss or loss of appetite?

· Have you traveled recently or been in contact with anyone who was sick?

Objective

The patient appears ill and fatigued, wearing a sweater despite hot weather.

Vital Signs:  B/P:     , HR:   , T: 100.5; SaO2:   ; Weight:   ; Height:     ; BMI:

1.  Physical Exam

Respiratory:

– Inspiratory crackles and diminished breath sounds on auscultation, particularly over the left lower lobes

– Dullness on percussion over the left lower lobe

Musculoskeletal:

Muscle aches reported, no joint swelling or erythema

Neurological:

Alert and oriented

2.  Point of Care (POC):

Pulse oximetry

Chest x-ray

 

Plan/Assessment

 

Differential Diagnosis:

1. Viral upper respiratory infection

2. Chronic bronchitis

3. Influenza

4. Tuberculosis

5. Congestive Heart Failure with Pulmonary Edema

WorkingDiagnosis

– Community-acquired pneumonia

Diagnostic Studies:

· Chest X-ray to evaluate for pneumonia or other lung pathology

· Complete blood count (CBC) to check for infection

· Basic Metabolic Panel (BM) to assess electrolyte balance and renal function

· Sputum culture and sensitivity

· Blood culture

Treatment:

· Start empiric antibiotic therapy for community-acquired pneumonia (azithromycin or doxycycline): Doxycycline 100 mg PO BID x 7 days.

· Antipyretics and analgesics (acetaminophen or ibuprofen)

· Increase fluid intake and rest

Referral

Patient will be referred to pulmonologist if no improvement  or if condition worsens.

Education

· Patient will be educated on the importance of completing the full course of antibiotics

· Patient will be educated on on recognizing signs of worsening condition (e.g., increased shortness of breath, chest pain, high fever)

· Encourage rest and adequate hydration

Health Maintenance

We will ensure patient is up to date with vaccinations, including influenza and pneumococcal vaccines

 

Diagnosis	Signs/Symptoms	Gold Standard Diagnostics	Gold Standard Treatment
COPD	Chronic cough, sputum production, dyspnea, wheezing	spirometry	Bronchodilators, corticosteroids, smoking cessation, pulmonary rehabilitation
Community Acquired Pneumonia	Cough, fever, chills, chest pain, dyspnea, fatigue, crackles, dullness on percussion	Chest X-ray, sputum culture, blood culture	Antibiotics (e.g., azithromycin, doxycycline), antipyretics, fluid rest
Atypical Pneumonia	Gradual onset, dry cough, headache, myalgia, fatigue, low-grade fever	Chest X-ray, PCR testing or atypical pathogens	Macrolides (e.g., azithromycin), doxycycline, supportive care
Acute Bronchitis	Cough (may be productive), wheezing, chest discomfort, low-grade fever	Clinical diagnosis, chest X-ray to rule out pneumonia	Symptomatic treatment (e.g.,antitussives, bronchodilators), hydration, rest
Asthma	Recurrent wheezing, SOB, chest tightness, cough, especially at night or early morning	spirometry, peak flow measurement	inhaled corticosteroids, bronchodilators, leukotriene modifiers
Tuberculosis	Persistent cough (more than 3 weeks), hemoptysis, night sweats, weight loss, fever	Tuberculin skin test (TST), interferon-gamma release assays (IGRAs), chest X-ray, sputum culture	Combination antibiotic therapy (e.g.isoniazid, rifampin, ethambutol, pyrazinamide)
Pulmonary Emboli	Sudden onset dyspnea, pleuritic chest pain, hemoptysis, tachycardia, hypoxemia	CT pulmonary angiography, D-dimer, V/Q scan	Anticoagulation (e.g., heparin, warfarin), thrombolytic therapy, surgical intervention in severe cases
COVID-19	Fever, dry cough, fatigue, loss of state or smell, SOB, body aches, sore throat, congestion	RT-PCR test, antigen test, chest CT scan	Supportive care, antiviral medications (e.g., remdesivir), corticosteroids (e.g., dexamethasone), monoclonal antibodies in certain cases
Upper Respiratory Infection	Nasal congestion, runny nose, sore throat, cough, sneezing, low grade fever, headache, malaise	clinical diagnosis	symptomatic treatment (e.g., decongestants, antipyretics, fluids), rest
Influenza	Sudden onset fever, chills, cough, sore throat, muscle aches, fatigue, headache,, runny or stuffy nose	rapid influenza diagnostic test (RIDT), RT-PCR	Antiviral medications (e.g., oseltamivir), supportive care (e.g., hydration, antipyretics, rest)