Acute Bronchitis Soap Note Assignment

Acute Bronchitis Soap Note Assignment

Acute Bronchitis Soap Note Assignment

SUBJECTIVE INFORMATION

Patient Initials: S.K                            Gender: Male                    Age:43 years old

 Chief Complaint (CC) “I have been having a cough for 12 days now”

History of Present Illness (HPI) S.K is a 43-year-old African American male that presented to the outpatient department with complaints of coughing 12/7. The patient was having an evening walk when she first started coughing. She states that the coughing sounds like “barking” and the condition has been getting worse in the last three days. It starts on the chest and radiates to the back.  Sleeping using a pillow makes the cough better but gets worse any time he drinks cold water.  The patient states that he has chest discomfort of 7/10 degrees according to the pain scale and nocturnal chills. In the last 1 week, the patient has noticed the production of white mucus. In the same week, the patient had a fever which was ameliorated using over-the-counter paracetamol 1 gram taken after every 8 hours. The associated symptoms entail general body weakness, fatigue and time to time shortness of breath. The patient denies experiencing any of such symptoms as nausea, vomiting, headache, abdominal pain and blood-stained mucus.

BUY A CUSTOM PAPER HERE

Medications:

mefenamic acid 250mg PO OD (last use: last evening

hydrochlorothiazide 25mg OD (Last use: this morning

 nifedipine 20mg OD (Last use: this morning)

Allergies: No known food and drugs allergies

Past Medication History: In his teenage years he developed gastroenteritis secondary to food poisoning and inflammatory bowel disease. In 2015 he was depressed after losing his job. The patient has been having chronic headaches and borderline hypertension.

Past Surgical History: He has never undergone any surgical procedure and he has never been transfused with blood.

Sexual/Reproductive History: He is married and actively engages in sex with his wife. He is negative for HIV/AIDS as well as STIs.

Social History: The patient is a construction worker and he is married with two children aged 4 and 7.  He has no religious affiliation. He smoked in his twenties but he has since quit and has never smoked since then. He does not drink or indulge in substance abuse.

Family History: Mother died of congestive heart failure with the paternal grandfather having COPD.

Review of Systems (ROS)

General: The patient states that he has no major health changes besides the cough.

Respiratory: He complains of chest discomfort, and dyspnea, he has been coughing, produces colourless sputum and has wheezing sounds.

HEENT: Eyes: Short-sighted. Ears, Nose, Throat: Hears sounds perfect, no throat pain, no abnormal nose discharge

SKIN/HAIR/NAILS: No skin discolouration or itching or rash. No acne or angioedema on his face and denies seeing any changes on his nails.

CARDIOVASCULAR: He feels chest pain at some point; neither oedema nor palpitations are present.

GASTROINTESTINAL: Normal appetite, no nausea, vomiting or diarrhoea. Abdominal pain absent. 

Musculoskeletal: He has no joint pain, muscle pain, swelling or any joint stiffness

Neurological: He denies feeling dizzy, seizures, and no “needles and pins” feeling on his legs.

Psychiatric: He denies feeling depressed and has no anxiety or suicidal thoughts.

Living Environment: The patient lives in one of the apartments in a city’s metropolitan. He states that the house is spacious and has access to a lot of natural light. There is no factory near his home but he occasionally meets with one of his friends that smokes about 10-15 cigarettes a day.

OBJECTIVE INFORMATION

Vitals; BP 121/83, Weights 143 lbs BMI: 22.6, Height 5ft 9-inch SPO2 96% RA.

General body Survey: The patient is an African American with a well build athletic body and he looks way younger than his real age. He speaks eloquently and his answers are congruent with questions.  He is well and appropriately dressed for the day’s weather. He is too calm and collected to be in such distress.

Physical Examination

Lungs

They are resonant throughout and have no abnormal sounds on auscultation. The breath sounds are vesicular

Thorax: They are symmetrical having an even expansion, absent body deformities, AP diameter is elevated and there is no tenderness. Supra/ infra or axillary lymphadenopathy.

Heart: Lifts, heaves and thrills absent. Regular S1, S2, no S3 or S4. Absent murmurs, rub, gallop or clicks.

Chest: Diaphragm looks lower and flat at the base.

Abdomen: Appears symmetrical, flat and with no lesion, herniation, scars or abnormal pulsations. Soft abdomen with normoactive bowel sounds in the four quadrants. No bruises or hums.

The liver can be palpated.

Back: Normal curvature, positive bilateral costovertebral angle tenderness.

HEENT: Head is normocephalic; eyes look reddish but no discharge and normal focusing; no discharge from the ears; no pain in the neck and throat is not blocked.

 ASSESSMENT

Diagnosis: Acute bronchitis (ICD-10; J20.9) is the primary diagnosis

Rationale

The clinical presentation of the patients points towards acute bronchitis, for example, severe productive cough, malaise, difficulty breathing and wheezing.  The sputum is white. Additionally, the patient has a family history of both heart and lung disease which makes it possible to focus on the symptoms that he is presenting with. The fact that his diaphragm looks lower and flatter points towards the diagnosis of bronchitis.  The liver can be palpated which shows that it could have been displaced as a result of overinflation. The fact that the patient has a friend who is a heavy smoker that they spend time together increases his risk of developing bronchitis. There is a need to carry out spirometry for lung function tests and he should have an x-ray to rule out pneumonia. Through this diagnostic measure, it will be possible to determine the amount of air that the patient’s lungs can hold and the rate of expiration. The rationale behind doing spirometry is to find out if the patient has any other issues besides bronchitis. According to the American College of Chest Physicians, a chest x-ray should be obtained only when the heart rate is more than 100beats/ minute, respiratory rate is more than 24 breaths per minute and oral body temperature is more than 38 degrees centigrade (Braman, 2018). Additionally, more work-up should include a complete blood count and chemistry for fever and dehydration. Differential Diagnosis

1. Asthma: It should be noted that in a third of the patients that present with cough, asthma is misdiagnosed as acute bronchitis.
2. Acute or chronic sinusitis
3. Bronchiolitis
4. COPD
5. Heart Failure
6. Pulmonary embolism.

 PLAN

1. Start Azithromycin 500mg PO once, then continue 250 mg once daily for 5 days. Evidence-based research suggests that antibiotic treatment for acute bronchitis has positive outcomes (Luisi et al., 2020). As the patient has no known allergies to the drug, he should take it.
2. Continue taking the mefenamic acid 250 mg PO and combine it with Sumatriptan for better outcomes. Law, Moore and Derry (2016) have it that such combination therapy leads to better outcomes.

Continue with hydrochlorothiazide 25mg once daily and use nifedipine sublingually. A growing body of research shows that the combination is effective in African Africans with primary hypertension.

Lab

A blood test to confirm the presence of infection; Chest X-ray to confirm or rule out the presence of pneumonia; urinalysis to look for possible infections.

Patient Education.

The patient should be advised to let the friend that smokes do it in his absence or avoid his company in totality to reduce the risk of acute bronchitis recurring and other complications.  They should be taught about the side effects of azithromycin. Increase the intake of fluids, and drink warm beverages frequently.  The patient was advised to take azithromycin following instructions given by the pharmacists without skipping the dose or stopping whenever his symptoms improve.

Follow-Up

The patients should be back at the facility in 7 days. By the time the patients come back, all the lab and test results, diagnostics and feedback will be ready from the referred specialist. In the next appointment, the patient will provide details on the effectiveness of the medication and inform the physician of the progress concerning the education plan.

References

Braman, S. S. (2006). Chronic Cough Due to Acute Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines. Chest, 129(1), 95S. https://doi.org/10.1378/CHEST.129.1_SUPPL.95S

Law, S., Moore, A., & Derry, S. (2016). Sumatriptan plus naproxen for the treatment of acute migraine attacks in adults. London, UK: Cochrane Database of Systematic Reviews.

Luisi, F., Roza, C. A., Silveira, V. D., Machado, C. C., da Rosa, K. M., Pitrez, P. M., Jones, M. H., Stein, R. T., Leitão, L. A. de A., Comaru, T., Mocellin, M., & Pinto, L. A. (2020). Azithromycin administered for acute bronchiolitis may have a protective effect on subsequent wheezing. Jornal Brasileiro de Pneumologia, 46(3), 20180376. https://doi.org/10.36416/1806-3756/E20180376

ORDER A PLAGIARISM-FREE PAPER HERE

Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up