This is a 61-year-old male with PMH of HTN, CVA, CAD, GERD, Atrial fibrillation, and Pulmonary Embolism
SOAP NOTE 5
Funmilola A Akerele
D’youville University
NUR 641 Clinical Practicum II in Adult Health/Aging Populations
10/26/2024
CC: productive cough of yellowish sputum that started about a week ago
ELOG#: 15347111
SUBJECTIVE: This is a 71-year-old black male with PMH of GERD who presented to the office with a productive cough of yellowish sputum that started about a week ago. The cough is associated with a runny nose, watery eyes, sore throat, body aches, and fatigue. Endorses generalized body pain as 6/10 intensity on the pain scale, describes it as continuous, not relieved with OTC medication. The patient denies fever, headache, earache, dizziness, chest pain, SOB
, or palpitations. He has not recently had contact with a sick person and has not traveled out of the country.
Vital Signs:
Ht(without shoes) 172 cm (5’8”). Wt. (dressed) 58.51 kg (184 lbs.) (BMI: 28.0 kg/m2) BP 120/60 mmHg (right arm seated); 125/62 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 70 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 9°F, Spo2: 100% Room air.
Eyes:
Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins are sharp, without hemorrhage or exudate: no arteriolar narrowing or A-V nicking.
Ears:
Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o’clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose
Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, no evidence of bleeding. Positive for rhinorrhea
Mouth:
Oral mucosa positive for redness and erythema. The dentition is good. Tongue midline. Tonsils are positive for mild swelling. Pharynx without exudates Positive for erythematous
Neck:
Neck Supple. Trachea midline. The thyroid isthmus is palpable, and lobes are not felt.
Lymph Nodes:
No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs:
Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Respiratory
: Positive for a productive cough with yellowish sputum. Negative for shortness of breath (SOB).
Cardiovascular:
Regular rate and rhythm, heart rate 70 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Abdomen:
soft, non-tender + BS, no guarding.
Diagnostics:
· Chest X-ray: To evaluate for any signs of pneumonia or other lower respiratory tract
· Sputum Culture and Sensitivity: To identify any bacterial pathogens
· COVID-19 and Influenza Testing: To rule out viral causes of respiratory symptoms.
· Rapid Strep Test or Throat Culture: due to sore throat, testing for streptococcal pharyngitis
Laboratory Tests:
CBC, BMP
Assessment: Allergic rhinitis of bilateral watery eyes, Runny nose, sore throat, and cough.
Acute nasopharyngitis. Productive Cough of yellow sputum for one week, generalized body aches, Sore throat, and body aches
Plan:
Medications:
Zithromax 250 mg z-pak tablet, take two tablets (500 mg) by oral route once daily for one day, then one tablet (250 mg) by oral route once daily for four days 5 Days;
Tessalon perle 100 mg capsule: take one capsule (100 mg) by oral route three times per day as needed for cough 10 Days
Cetirizine-PSE er 5-120 mg tab, take one tablet by oral route every 12 hours.
Flonase allergy RLF 50 mcg SPR: inhale two sprays (100 mcg) in each nostril by intranasal route once daily.
Omeprazole DR 20 mg tablet; take one tablet once a day.
Acetaminophen 350 tabs, take two tabs orally q6h PRN for pain.
Education:
The patient was educated that infections are typically self-limiting but can cause discomfort lasting up to one to two weeks.
The patient was educated about Signs and Symptoms to Monitor for worsening symptoms
· Increased SOB.
· Persistent or high fevers.
· Chest pain or difficulty breathing.
· Blood in the sputum.
The patient was Encouraged on proper hygiene practices to prevent the spreading of the infection
· Frequent handwashing with soap and water.
· Using a tissue or elbow to cover the mouth and nose when coughing or sneezing.
· Avoid close contact with an immune-compromised individual
The patient was educated on adequate hydration and rest so that the body can recuperate.
Medication Adherence: The patient was educated on the importance of completing all prescribed antibiotic medications, even if symptoms improve before the medication is finished.
Avoid consuming milk within 30 minutes of antibiotic usage.
Follow-Up: RTC in 2 weeks; the result of the imaging tests will be explained.
Referral:
Pulmonologist: Pulmonary function tests (PFTs) can be utilized to assess chronic bronchitis, asthma, or other chronic respiratory conditions.
Otolaryngologist (ENT): The ENT can provide a thorough evaluation and possibly nasopharyngoscopy to identify any underlying issues.
Gastroenterology is due to a history of GERD for possible medication reconciliation and continuation of care.
