Week 4 SOAP Note
Submit a SOAP note in a Word document on a 69-year-old African Caucasian male who comes to the Primary clinic with symptoms of COPD Exacarbation.
The SOAP Note
Title: Adult Pulmonary (COPD)
Please add citations to every idea in the assessment, planning, Education, follow-up, and diagnosis areas. Every idea must be cited and referenced in 7th APA format.
It requires a primary Diagnosis and 3 different diagnoses, all with ICD-10 codes.
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Please use evidence-based references such as GOLD, which is a guideline used in the treatment of COPD
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This SOAP Note will be presented to my instructor and classmates on Video. Please give an outstanding work.
This is a sample expected SOAP below.
SOAP Note Week Four
Student Name
Name of Institution
Course Name:
Professor’s Name followed by credentials
October 1, 2020
SOAP Note Week Two
ID: M M, DOB 1/1/2000, age 20, Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.
Subjective:
CC: “Cough, runny nose, and sore throat for 7 days”
HPI:
28 year old Hispanic male presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently, he reports his symptoms are controlled with Dayquil and Nyquil. He reports his cough as mild, worsened when lying flat. Reports intermittent chills with highest temp at home was 99 degrees. Patient is here to see if he needs antibiotics. He rates his pain in his throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil but returns when that wears off after an hour. Denies headache, denies being around any other sick contacts and denies recent travel.
Past Medical History:
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Medical problem list
Asthma until high school,
Chickenpox at age 2
Sinus infections-chronic, GERD
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Surgical:
Tonsillectomy (1998),
Wisdom Teeth Removal (2005)
Allergies:
No known drug allergies.
Food allergies:Strawberries (rash),
Denies seasonal allergies
Medications:
1. Dayquil 15ml 3-4 times daily
2. Nyquil 15ml HS
3. No prescription medications, denies NSAID use or Tylenol
Vaccinations:
Received all childhood vaccines
Last flu shot given Oct 2019.
Social History:
Chemical history:
Denies tobacco/e-cigarette use.
Occasional beer once every 2-3 months. Last drink 2 months ago
Engaged, works in IT, Hobbies include archery.
Family History:
Mother age 60-Diabetes II (deceased)
Father age 61, HTN, DM
Sister 42yo HTN
Maternal Grandma Dementia Deceased age 67
ROS:
General: Denies weight change, weakness, fatigue,
(+)fevers..
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing changes, tinnitus, earaches, infection, discharge.
(+) FOR RHINORRHEA. No sinus pain or epistaxis.
(+) SORE THROAT,
(+) HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth.
Last dental exam was 4 months ago.
C/V: Denies chest pain, palpitations.
Pulmonary:
(+)NON-PRODUCTIVE COUGH, denies hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: Denies headache, dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal or environmental allergies
(+) chronic sinus
infections
Objective
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8
Labs, radiology or other pertinent studies: Rapid strep negative this visit
Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.
HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa
reddened.
Inferior turbinates with bilateral erythema with
clear exudate. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa with
erythema, tongue mobile without lesions, tonsils absent.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid
palpated. Trachea midline.
Neuro: Alert and oriented x 4. Appropriate, answers all questions.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.
(***notice not all systems are in the PE when doing a focused exam on a problem)
A:
Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS
1. Viral pharyngitis – most likely as evidenced by clear exudate in nares, sore throat, cough, low grade fever (Stead, 2019). (←←←←←that is a practice treatment guideline)
2. Strep Throat – not as likely; low grade fever could be higher but Nyquil/Dayquil contains Tylenol but appearance and 7 days duration, lack of sick contacts and negative rapid strep test performed here in office this visit (Stead, 2019).
3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.
4. Sinusitis- he has chronic infections with current erythema in turbinates, however he has no pain on palpation of sinus cavities, exudate is clear, his nares are patent, and he reports no pressure.
DX: Viral pharyngitis
Plan:
· Diagnostics
In house throat swab for rapid strep – negative.
Chest Xray, CBC, BMP (Stead, 2019).
· Treatment (specific medication with dosages here if this applies)
– Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).
– Continue OTC Dayquil/Nyquil 15ml PRN per directions on the box
· Education
– Safe dosing discussed, sedation may occur with Nyquil, avoid driving or
operating heavy machinery after taking. Do not exceed 4000 mg tylenol in
a day or take additional products with Tylenol.
– Do not drink alcohol while taking these medications.
– Encourage tea with honey and lemon to help with cough and sore throat.
– Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.
– Do not drink alcohol while taking these medications.
– Cover mouth when coughing, do not drink after other people
· Follow-up
Return to office in 3-4 days if symptoms do not start to improve, or the
emergency room.
Call 911 or go to ER for trouble breathing or any other emergent concern
(Stead, 2019).
References:
Cash, J. & Glass, C. (2019).
Family practice guidelines. New York, NY. Springer.
Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis
(Ed.).
UpToDate Retrieved February 12, 2020 from:
in-adults
