Soap note review

Description

Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Case study 1

Subjective

CC: Shortness of breath and cough

HPI: Mr. Hendrix a Caucasian male who complains of SOB and cough that started a few days ago. The patient describes SOB as severe and constant. The patient reports that walking makes the SOB symptoms worse and nothing improves his SOB. The patient reports that he coughs with clear phlegm. The patient also reports experiencing fatigue. The SOB get worst at night.
Current Medications: Diuretic medications

Allergies: No known allergies

Past medical history: CHF

Social Hx: Mr. Hendrix smoke 3 cigarette per day

Fam History: Not mentioned.

ROS:

General: Positive for fever, chills, night sweats, and fatigue.

HEENT: No vision changes, visual disturbances, injury, or history of eye disease. No nasal congestion, nosebleeds, or postnasal drip. Hearing loss and pain noted to right ear only. No drainage or tinnitus.

Throat: No sore throat, hoarseness or difficulty swallowing.

Skin: Cool and dry, no rash, lesions, itching, or pigment changes

Cardiovascular: No chest pain, palpitations, edema, or exercise intolerance

Respiratory: Positive for productive cough and SOB.

Gastrointestinal: Distended abdomen, No nausea, vomiting, heartburn, indigestion, constipation or diarrhea.

Genitourinary: No urinary urgency, hesitation, frequency, pain, or incontinence.

Neurological: No headache, dizziness, loss of coordination, tremors, or numbness.

Musculoskeletal: No muscle pain, joint pain, joint stiffness, or muscle weakness.

Hematological: No bruising, bleeding, or history of anemia.

Lymphatics: No tenderness or enlargement of the lymph nodes.

Psychiatric: No anxiety, depression, suicidal or homicidal ideations.

Endocrinological: No heat/cold intolerance, increased thirst, or increased urination.

Allergies: No history of asthma or allergies.

OBJECTIVE:

VITAL SIGNS: T 97.9 R 22 labored, P 94 B/P 162/90 02 sats 92% at room air, wt 215

GENERAL: Patient awake, alert, and oriented x3. Patient appears anxious noted wringing hands constantly. Patient answers questions and responds appropriately. Patient’s posture is tense, but his movements are well coordinated. Patient well-dressed with no body odor

SKIN: Cool and dry

CARDIOVASCULAR: Heart rate is regular with good S1, S2; with S3 extra heart sound with heart murmurs present with 3/6 systolic murmur

RESPIRATORY: Thorax is symmetrical, with vesicular breath sounds with scattered rales all throughout the lung fields, no rhonchi, or wheezes; breath sounds heard.

GASTROINTESTINAL: Abdomen is distended with normoactive bowel sounds auscultated in all 4 quadrants.

PERIPHERAL VASCULAR: 3+ peripheral edema noted extending to the knee bilaterally,

He has 2+ dorsalis pedis pulses bilaterally

Diagnostic results: Blood work and EKG to rule out cardiac involvement. Chest x-ray to check for pneumonia, pulmonary emboli (PE), and any other reasons patient is having shortness of breath (González, Martínez, J Romero, & Belmonte, 2018). Complete blood count to check white count for infection and hemoglobin since the patient has been coughing.

ASSESSMENT:

Differential Diagnoses:

  1. Pneumonia

Pneumonia is a lung infection caused by bacteria, viruses, and fungi that causes the alveoli in the lungs to become inflamed. When the alveoli become inflamed, they fluid instead of air causing productive cough, dyspnea, fever, chills, and fatigue (Driver, 2014). Pneumonia was chosen as a possible diagnosis based on the patient’s symptoms and history of smoking. According to Driver (2014), cigarette smoking increases the risk of developing pneumonia.

  1. Acute Bronchitis

Acute bronchitis is a lung infection caused by viruses, bacteria, and airway irritants that caused the lining of the bronchial tubes to become inflamed (Hart, 2014). Inflammation of the bronchial tubes causes a productive cough, thick phlegm production, fatigue, wheezing, and dyspnea. Acute bronchitis was chosen as a possible diagnosis based on the patient symptoms as compared to common symptoms of bronchitis and the patient’s history of cigarette smoking, which can cause acute or chronic bronchitis (Hart, 2014).

  1. Chronic Obstructive Pulmonary Disease (COPD)

COPD is a chronic inflammatory lung disease caused by long-term exposure to airway irritants such as cigarette smoke. Chronic exposure to airway irritants causes damage to alveoli and bronchial tubes which causes symptoms like a cough, phlegm production, dyspnea, wheezing, fatigue, and activity intolerance (Roche et al., 2015). COPD was chosen as a possible diagnosis based on the patient’s history of cigarette smoking which is the number one cause of COPD (Roche et al., 2013).

  1. Lung Cancer

Lung cancer is a disease that causes abnormal cancerous cells to divide uncontrollably, spread, and destroy healthy cells and tissue (Ridge, McErlean, and Ginsberg, 2015). Lung cancer causes symptoms like a productive cough, blood-tinged sputum, dyspnea, wheezing, and fatigue. Lung cancer was chosen as a possible diagnosis based on the patient’s symptoms and history of cigarette smoking. History of heavy cigarette smoking is the most common cause of small cell lung cancer (Ridge et al., 2015).

  1. Pleurisy- M J has symptoms of pleurisy which are inflammation of the tissues that line the lungs and chest and can cause coughing, chest pain that is worsened by breathing, and shortness of breath (Huether & McCance, 2017).

References

Cukic, V. (2015). The Most Common Detected Bacteria in Sputum of Patients with the Acute Exacerbation of COPD. Materia Socio-Medica, 25(4), 226–229. https://doi-org.ezp.waldenulibrary.org/10.5455/msm.2013.25.226-229

Driver, C. (2014). Understanding pneumonia: anatomy and pathology. Nursing & Residential Care, 16(3), 136. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=94574404&site=eds-live&scope=site

Ekpo, E. U., Egbe, N. O., & Akpan, B. E. (2015). Radiographers’ performance in chest X-ray interpretation: the Nigerian experience. The British Journal of Radiology, 88(1051), 20150023. https://doi-org.ezp.waldenulibrary.org/10.1259/bjr.20150023

Fogel, N. (2015). Tuberculosis: A disease without boundaries. TUBERCULOSIS, 95(5), 527–531. https://doi-org.ezp.waldenulibrary.org/10.1016/j.tube.2015.05.017

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis,

MO: Mosby.

Hart, A. M. (2014). Evidence-based diagnosis and management of acute bronchitis. The Nurse Practitioner, 39(9), 32–39. https://doi-org.ezp.waldenulibrary.org/10.1097/01.NPR.0000452978.99676.2b

Ridge, C. A., McErlean, A. M., & Ginsberg, M. S. (2015). Epidemiology of Lung Cancer. Seminars in Interventional Radiology, 30(2), 93–98. https://doi-org.ezp.waldenulibrary.org/10.1055/s-0033-1342949

Roche, N., Chavannes, N. H., & Miravitlles, M. (2015). COPD symptoms in the morning: impact, evaluation and management. Respiratory research, 14(1), 112.

Sample Solution

ACED ESSAYS