NU 650 Week 3
Subjective
Patient name: F.P.
Race/Ethnicity: American
DOB: 1/08/1955
Age: 68y
Marital Status: N/A
Chief Complaint (CC): “I have been having trouble breathing. In addition, I have a cough that has lasted for three days but got worse in the past day since I smoked.
History of Present Illness (HPI): A white man, 68 years old, came to the hospital office with a cough. F.P. says that he has also been having trouble getting enough air. According to F.P., the symptoms of coughing and lack of breath have been bad and constant for a long time, three consecutive days. Initially, he resisted seeking medical attention, but over three days, he observed a deterioration in his physical well-being. F.P. has sought medical attention twice this year due to a persistent cough and respiratory difficulties. During F.P.’s most recent two medical consultations, he received a diagnosis of chronic obstructive pulmonary disease (COPD). Five months ago, he was treated properly for the first time. His health got better after the treatment and was back to normal. At first, F.P. did not think the cough was a big deal because it was not too bad. F.P. says that his habit of smoking made the cough worse in just 24 hours. He also says that his phlegm went from white to green and thick. F.P. is becoming increasingly dependent on his albuterol inhaler, which has led him to go to the doctor. F.P. says he has no fever, swelling around the edges of his body, chest pain, or tremors. However, F.P. says that he smokes half a pack of cigarettes daily. F.P. has been taking care of his health with an oxygen inhaler for the past three days. F.P. says his cough and lack of breath are a nine on a scale from 0 to 10. F.P. claims that to help in breathing and to assist him in coughing, he uses an inhaler that contains albuterol a minimum of six times each day when he has trouble breathing.
Review of Systems (ROS):
- General: Admits breathlessness. Confesses to hacking. Denies feeling chest pain. Denies experiencing a fever, peripheral edema, appetite loss, or changing weight. Denies experiencing pain or weakness.
- Skin: The patient denies experiencing rashes or other skin changes and admits to having eczema.
- Hair/nails: The patient denies hair loss, nail alterations in color, shape, or stiffness, along with modifications in the quality of their hair.
- HEENT: denies scintillating scotoma as well as vision blur. Denies the existence of sharp vision and any eye pain or injury. Denies that hearing or ear pain are complex issues. Denies discharge, an ear infection, or recent ear damage; denies frequent sniffles or concerning nasal hemorrhage; denies mouth ulcers, plaques, changes in taste perception, tooth abscesses, tonsil illnesses, or difficult swallowing.
- Respiratory: confirms increasing green sputum, shortness of breath, and a productive cough for the past three days. Denies cyanosis, discomfort in the chest, or injury.
- Cardiovascular: Refuses symptoms such as palpitations, chest discomfort, orthopnea, syncope, coughing, and dizziness,
- Peripheral Vascular: The patient denies peripheral edema, petechiae, bruising, or unexpected bleeding.
- Musculoskeletal system: denies experiencing joint pain, tense muscles, weakness, swelling, or injury.
- Neuro: denies having seizures, abnormalities in their gait, vertigo, numbness, tingling, or searing discomfort.
- Gastrointestinal: denies feeling queasy or having the flu. Refuses to accept hemorrhoids or stomach aches.
- Urinary: The patient asserts the absence of nocturia, polyuria, burning, sense of urgency, hesitation, or striving records of genital information. LMP: N/A, denies sores drainage.
- Hematologic: The patient denies ever having had anemia. The patient says they have never been hurt, bled, or had a blood transfer.
- Endocrine: The patient negates any prior occurrence of diabetes, heightened appetite, thirst, or urination.
Past Medical History (PMH):
Chronic illness: When F.P.’s medical history is examined clinically, it becomes clear that he had COPD and had been successfully treated for it five months prior. For the past 35 years, he has smoked. He currently smokes a half-pack of cigarettes daily and is a strong smoker. His growth history is unremarkable; a colonoscopy five years ago revealed no abnormalities. The nutritional history of F.P. reveals that he occasionally consumes a good diet. F.P. has never received a blood transfusion; his FOBT test was negative a year ago. Mumps and chickenpox are indicated in F.P.’s past medical history.
Social History: F.P. lives in an apartment that is rented. There is no known marital information for the client. There is no information on the patient’s employment. F.P. has no prior employment experience. F.P. has smoked for 40 pack years, which suggests he has been doing so for the past 35 years. Currently, the patient admits to smoking a half-pack of cigarettes every day.
Past Surgical History: He has no history of surgery.
Family History: The cause of death of F.P.’s mother was a heart attack, and the cause of death of F.P.’s father was diabetes.
Medications:
- For wheezing and dyspnea, the patient is now utilizing Ventolin HFA 90mcg (Albuterol) Aerosol MDI: 180 mcg (2 puffs) breathed P.O. every six hours as recommended.
Immunizations: The immunization records for F.P. are current. The patient has been immunized against influenza and pneumococcal disease.
Allergies: F.P. has no known allergies to medications, foods, latex, environmental factors, or herbal remedies.
Functional Assessment: Health Maintenance Practices
- Activity/exercise:rejects regular exercise
- Sleep/rest: N/A
- Nutrition/elimination:Admits to occasionally eating a healthy diet.
- Relationships/resources:P. lives alone.
- Spirituality: The patient claims to be a protestant who attends church on Sundays.
- Coping and stress management:The patient reports experiencing a consistent level of moderate stress due to various life pressures and feels that she requires therapy or medicine to assist him in managing his stress.
- Safety:P. maintains firearms in the house along with a smoke detector. The patient affirms that he always buckles up when driving or traveling by public transportation. F.P. acknowledges that he keeps firearms at home but refuses to disclose where.
- Screenings:The patient had their most recent colonoscopy five years ago. The patient will have a second colonoscopy the following year. The patient’s history reveals no information regarding mammography screening, and F.P. provides no information regarding PSA, the prostate cancer screening test. Regarding the Pap smear exam, F.P. is clueless. The patient’s Mini-Cog test came back normal.
Objective
- General:P., a 68-year-old Caucasian male, presents with breathlessness. The individual exhibits a robust physical appearance, characterized by a lack of paleness, a normocephalic head, the absence of any trunk or extremity deformities, and no signs of gait imbalance.
- Vital signs: Temp: 98, B.P.: 120/75, H.R.: 94/min, R.R.: 22, O2: 94% RA
- Height:71 inches Weight: 150 BMI: 21
- Examination:
- HEENT:Head is normal in shape. Hair is thick and distributed uniformly throughout the head. Eyes: PERRLA, symmetric, complete EOM. There were no symptoms of palpebral ptosis, conjunctival/scleral injection, tearing, or ocular discharge. Ears: With no redness, discharge, or wax from the ears blockage, symmetric, bilateral T.M.s appear pearly grey. Test results from Weber and Rinne indicate no hearing loss. Nose/Mouth/: Healthy teeth, a midline septum, and pink mucosa. No blisters in the mouth, ulcers, glossitis, or uvula abnormalities. There is no oropharyngeal redness, swollen tonsils, exudate, or tonsils without white patches. Throat: the Pharynx and the Tonsillar, Fossa: normal, Tonsils: No tonsils, a soft palate N.L.
- Lymph Nodes: No goiter, nodules, torticollis, cervical discomfort, swollen lymph nodes, or restricted movement are present.
- Respiratory: 22 breaths per minute. Simple breathing; symmetrical chest rise; no cyanosis. Thorax has good expansion and fremitus, is symmetrical, and is not tender. The lungs ring out. The breath sounds vesicular; there are no crackles or rhonchi. There was a minor wheeze heard during forced expiration. Wheezing is not stopped by forced coughing. Diaphragms bilaterally shrink by 3 cm; there are no unintentional noises.
- Cardiovascular:S1 and S2 are the heartbeats. No S3, peripheral edoema, pericardial rub, tachycardia, JVD, bilateral basilar crackles, or murmurs.
- Abdomen: The abdomen exhibits a spherical shape, displaying a soft consistency, and auscultation reveals the presence of bowel sounds in all four quadrants. There were no observations of organomegaly or bruits.
- Peripheral Vascular System: The extremities exhibit warmth, symmetry, and absence of edema. There were no changes observed in either stasis or varicosities. The calf lacks pain sensation and a high degree of flexibility. There were no audible abdominal or femoral bruits detected. The axilla and epitrochlear lymph nodes can be detected with palpation in a normal individual. The brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibia pulses exhibit bilateral symmetry and are graded as 2+ in strength. The Allen test for arterial perfusion yielded a negative result.
- Cranial nerves:Complete WNL from CNII to C.N. 12. Coordination: No unnecessary motions occur. The stance fits. Gait includes normal steps, a stable base, arm swing, and turning. Heel-toe walking is widespread. Motor: Normal muscle tone and size. Complete bilateral strength. They are flexing the R/L arm against maximum resistance at 5/5 muscle power. Light touch and pinprick sensations persist in the digits of the hands and feet. The right biceps reflexes were observed to be within normal limits, specifically graded as 2+ on the reflex scale. The measurement of the left biceps indicates a score of 2+, which falls within the usual range. The right triceps muscle exhibits a grade of 2+, within the normal range. The strength of the left triceps muscle was assessed and found to be within normal limits, with a grade of 2+. The patella on the right side exhibits a 2+ rating, indicating normalcy. The left patella exhibits a grade 2+ finding within the normal range. The right ankle exhibits a 2+ rating, indicating a normal condition. The left ankle exhibits a score of 2+, within the normalcy range.
Assessment
- Bronchiectasis: This chronic lung disease causes the airways to expand and become permanently damaged (O’Donnell, 2022). Due to mucus buildup, recurring lung infections, and shortness of breath, patients frequently experience continuous coughing with sputum production. Prior respiratory infections, genetics, or underlying illnesses like cystic fibrosis are the usual causes. Treatment focuses on removing mucus, controlling infections, and, in severe cases, surgical intervention. Diagnosis involves imaging tests like CT scans (O’Donnell, 2022).
- Acute bronchitis is an acute bronchial tube inflammation typically brought on by viral infections (Di Mauro et al., 2019). It begins with a sudden onset of cough, frequently followed by a mild fever, sore throat, and chest pain. Contrary to bronchiectasis, acute bronchitis typically disappears after a few weeks of rest and symptom management, including fluids and over-the-counter drugs (Di Mauro et al., 2019).
- Congestive heart failure (CHF) is a cardiac condition that causes fluid retention and lung congestion due to the heart’s inability to pump blood efficiently( Naik et al., 2021). Breathlessness, exhaustion, coughing (typically greater at night), and swelling ankles are among the symptoms. Due to lung congestion, CHF might mimic bronchiectasis, but it is a cardiovascular condition. Various tests, including echocardiograms, are used to diagnose, and medicine, a lifestyle change, and occasionally surgical procedures like heart transplantation are used to treat the condition (Pambudi & Widodo, 2020).
PLAN
- Plan: • Verify the diagnosis. If the situation worsens, follow up with an asthma and allergy expert.
- Diagnostics: Spirometry, chest X-ray,
- Labs: Although they are not typically required, ABGs or arterial blood gases can be used to measure how bad something is.
- Pharmacologic intervention: Albuterol 90mcg Ventolin HFA 180 mcg (2 puffs) inhaled P.O. every 6 hours for dyspnea and wheezing. Medrol Dosepak 4mg oral tab, taper P.O. for six days as indicated. Azithromycin (tab) 500 mg, divided into 250 mg daily for four days. Tylenol 650mg=2tabs, orally every 6 hours, as needed for fever and discomfort. Duoneb 1vial=3ml, inhalation every 6 hours as needed for SOB(Persson et al., 2019).
- Non-pharmacologic intervention: If people with COPD use the inhaler, they might not have the desired outcomes. The patient should take the prescribed medications (Persson et al., 2019). Smoking cessation may help someone with COPD delay how quickly it gets worse. The person should eat well daily. Following a doctor’s orders, COPD sufferers can also receive the pneumococcal vaccine.
- Referrals: None
- Education: Someone diagnosed with COPD should know that it is a serious disease that worsens over time and cannot be cured. The patient could go to pulmonary therapy to learn routines and ways to breathe. Patients should stop smoking, stay busy to improve respiration and eat well-balanced diets (Dailah, 2022).
- Follow up: Return in five days or sooner if necessary for a general evaluation of your development.
References
Dailah, H. G. (2022). The therapeutic potential of small molecules targeting oxidative stress in treating chronic obstructive pulmonary disease (COPD) is a comprehensive review. Molecules, 27(17), 5542. https://doi.org/10.3390/molecules27175542
Di Mauro, Ammirabile, Quercia, Panza, Capozza, Manzionna, & Laforgia. (2019). Acute bronchiolitis: Is there a role for lung ultrasound? Diagnostics, 9(4), 172. https://doi.org/10.3390/diagnostics9040172
Naik, M. S., Pancholi, T. K., & Achary, R. (2021). Prediction of congestive heart failure (CHF) ECG data using machine learning. Intelligent Data Communication Technologies and Internet of Things, pp. 325–333. https://doi.org/10.1007/978-981-15-9509-7_28
O’Donnell, A. E. (2022). Airway clearance and Mucoactive therapies in bronchiectasis. Clinics in Chest Medicine, 43(1), 157–163. https://doi.org/10.1016/j.ccm.2021.12.004
Pambudi, D. A., & Widodo, S. (2020). Posisi Fowler Untuk Meningkatkan Saturasi Oksigen Pada Pasien (CHF) congestive heart failure Yang Mengalami Sesak Nafas. Ners Muda, 1(3), 156. https://doi.org/10.26714/nm.v1i3.5775
Persson, H., Lyth, J., Wiréhn, A., & Lind, L. (2019). <p>Elderly patients with COPD require more health care than elderly heart failure patients in a hospital-based home care setting</p>. International Journal of Chronic Obstructive Pulmonary Disease, 14, 1569-1581. https://doi.org/10.2147/copd.s207621
NU 650 Week 3
Grading Category: Assignments: SOAPs
Overview
The purpose of this assignment is for you to obtain and document a comprehensive health history.
Instructions
To complete your assignment:
- Identify a patient in the clinical setting or friend, peer, or family member who you can interview for a comprehensive health history as though they were a new patient to your office.
- Conduct an interview and document the comprehensive health history and subjective review of systems.
Chapter 1 of the Bates’ Guide to Physical Examination and History Taking provides an example.
Please refer to the Grading Rubric for details on how this activity will be graded.
Please look at the sample SOAP Note link below. Start following the link and answering the questions. it will open to SOAP Note Guidelines and SOAP Example. Please do Robert and Jessica the same.
Please also follow the attached Rubric carefully for us to get the full points
https://lmscontent.embanet.com/Media/RC/NU650/NU650-w05-m01/
SOAP Note Guidelines and SOAP Example
Review the Comprehensive SOAP Note Guide for further details about the contents of a SOAP note.
SOAP Note Example
SS: (Subjective)
OO: (Objective)
AA: (Assessment)
PP: (Plan)
References
- Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandburg-Cook, J. (2017). Primary care: A collaborative practice (5th Ed.). St. Louis, MO: Elsevier
- Domino, F. J. (2019). The 5-minute clinical consult. 2007 ed. Philadelphia: Lippincott Williams & Wilkins.
- Durham, C. O., Fowler, T., Smith, W., Sterrett, J. (2017). Adult asthma: Diagnosis and treatment. The Nurse Practitioner, 42(11), 16-24. doi:10.1097/01.NPR.0000525716.32405.eb
- Ferri, F. F. (2018). Ferri’s clinical advisor 2018: 5 books in 1. Philadelphia, PA: Elsevier.
- McCracken, J. L., Veeranki, S. P., Ameredes, B. T., & Calhoun, W. J. (2017). Diagnosis and management of asthma in adults. JAMA, 318(3), 270-290. doi:10.1001/jama.2017.8372.
- Papadakis, M. A., & McPhee, S. J. (2020). Lange 2020 Current Medical Diagnosis & Treatment (59th end). New York: McGraw-Hill Professional.
