Soap Note Soup Note: COPD Exacerbation
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The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient. 1
SOAP NOTE COPD
Miami Regional University
Age: 65 years old
Chief complaint: “I’ve more shortness of breath than usual”
History of present illness: Patient is a Hispanic white male 65year old, with COPD and heavy smoker, history , who has experienced 2 episodes of pneumonia in the last 3 years. In this occasion comes complain of increased shortness of breath more than usual, with productive cough and yellowish sputum and mild fever of 99.8 F for the last 2 days. Patient is on bronchodilator PRN (Ventolin HFA). Never has been hospitalized for any CAP. Patients works as Flooring Installer where is expose to dust, although states using always protection against it.
Past Medical History
Chronic Condition: COPD
Current Medication: -Ventolin HFA (Albuterol) Aerosol metered-dose inhaler 90mcg (base)/actuation: 180 mcg (2 puffs) inhaled PO q4-6hr, PRN.
Hospitalization: None, in last 2 years.
History of mental illness: None
Physical trauma or falls: None reported during the last year.
Exposure: No blood transfusions or received other blood components or tissues.
Environmental exposure: Patient works as flooring installer and is exposing to dust for more than 20 years.
Exercise: Patient refers frequently daily exercises.
Diet: Patient refers a “healthy diet” rich in whole grains, vegetables, fruits and proteins.
Patient is single, and lives with his daughter in an apartment. The relationships between family members are good.
Toxics Habits: Current heavy smoker (2 packs of cigarettes daily for more than 20 years). Client denies using drugs or alcohol.
Educational level: Middle School.
Sexual Behavior: Patient is heterosexual, and he reported one sex partner during the past year (occasionally). Client said that he always uses condom. No risk behavior for STDs.
Allergies: NKDA, No Food or Seasonal Allergy
Family Medical History: Mother died (Melanoma). Father died (Lung cancer).
Last annual physical exam: 2/3/2020
Immunizations: Flu Vaccine: 01/12/2020, Pneumonia Vaccine: 5/15/2019
PSA: 2/3/2020 (Normal)
Colonoscopy: 10/20/2018) (Negative)
Abdominal Sonogram R/O AAA: 4/24/2020 (Normal)
Pulmonologist F/U every 6 months (Last re-evaluation/spirometry 9/30/2020)
Review of systems (ROS)
Systemic: Mild fever 99.8 F for the last 2 days, no weight loss, mild diminished appetite and mild generalized weakness. No pain at this time
Head: No headache. No sinus pain is reported, no mass, no trauma.
Neck: No pain or stiffness reported in this area. No swollen glands in the neck.
Eyes: No redness, pruritus or secretion. Denies blurred vision, double vision or other conditions.
Oto-laryngeal: No change in hearing, ringing in ears, neither ear pain. Not presence of sinus/nasal congestion or bleeding gums.
Breasts: No symptoms such as pain, fullness sensation or discharge.
Cardiovascular: Denies chest pain, palpitations, discomfort neither occasional episodes of irregular rhythm.
Pulmonary: Worsen of shortness of breath which improves with routine measures such as albuterol oral inhalation, increased productive cough, non-bloody yellowish sputum, no chest pain.
Gastrointestinal: No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.
Genitourinary: No pain, hematuria or changes in urinary habits. No cloudy urine or bad smell. No penile discharge.
Endocrine: No symptoms. No polyuria, no polyphagia.
Hematologic: Denies easy bruising, loss of hair, heat/cold intolerance, and change in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.
Musculoskeletal: Denies limited range of mobility, joint pain or limited ROM. Denies difficulty walking or trouble reaching above head.
Neurological: Denies migraine, balance problems, seizures or fainting lightheadedness, tremors or balance problems. Denies muscle weakness, numbness or tingling.
Psychological: Not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, No trouble falling or staying asleep unless shortness of breath or cough wakes him up if he don’t control it before sleeping. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.
Skin: The patient denies presence of white or brown spots, ulcer, ecchymosis, or new nevus. No pruritus, skin rash or unexpected skin lesion.
BP-sitting L: 128/78 mmHg
BP cuff size: Regular
Pulse Rate-Sitting: 91 bpm
Pulse Rhythm: Regular
Respiration Rate: 20 per min
Temp-Tympanic: 99.1 F.
Weight: 168 lbs.
Body Mass Index: 24.8
Oxygen Saturation: 95 %
Pain Scale/Rate: 0/10
General appearance: The patient is awake, alert, well developed, well-nourished and well groomed.
Head: The skull is normocephalic, atraumatic and without masses. The patient’s facial expression and facial contours are normal; the parotid glands are not enlarged. The sinuses are non-tender. Palpation of the temporal and masseter muscles reveals normal strength of muscle contraction. There is symmetry of the nasolabial folds. There is no facial droop.
Neck: No visible mass and skin with normal coloration. No palpable masses or tenderness, trachea is midline, thyroid without nodules, no JVD, no lymph nodes.
Eyes: Extraocular movement in both eyes is symmetric. PERRLA, sclera is white, conjunctiva pink, no noted discharge. Normal visual acuity.
Ears: External auditory canal and meatus are normal. No swollen or reddened. Bilateral tympanic membranes were intact and pearly gray with light reflex. No erythematous, scarred or hemorrhage. No pus or serous exudate. No hearing loss.
Nose: No external deformities of the nose. Nasal mucosa: moist and pink with clear drainage, septum midline. Nasal turbinate: no erythematous, no swollen. No sinus tenderness.
Oral Cavity: Oral mucosa moist and pink. Gums: normal appearance without swollen, bleeding or hypertrophy. Teeth, the dentition are complete and good hygiene.
Pharynx: Moist and pink with tonsillar enlargement without lesions, plaques or exudate. No petechial, Tongue: moist, no lesions.
Lymph Nodes: No adenomegaly on observation on palpation in any of the ganglion’s chains.
Respiratory: The patient is relaxed and breathes without effort but with mild use of accessory muscles to breath, the patient is not cyanotic. The AP diameter of the chest is normal with shape consistent with barrel chestThe chest expands symmetrically upon inspiration. Upon palpation of the chest wall there is no tenderness or masses. Tactile fremitus is normal and symmetrical. The lungs are clear to percussion. To auscultation there are scattered rhonchi present bilaterally accompanied with mild wheezing, lung sounds bilaterally. No signs of consolidation, such as decreased or bronchial breath sounds, dullness to percussion, tactile fremitus and egophony noted upon auscultation.
Cardiovascular: Regular rate and rhythm, heart sounds of S1 and S2, no extra heart sounds, murmurs or bruits noted. PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard. No gallops, murmurs, or opening snaps.
All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test was normal.
Gastrointestinal: The abdomen is soft and nontender; there is no guarding or rigidity. Bowel sounds are normal. There are no palpable masses. There is no hepatosplenomegaly. There is no costovertebral angle (CVA) tenderness.
Genitourinary: The penis is without erythema, lesions, or masses. There is no discharge from the urethral meatus. No scrotal swelling or discoloration. Testes descended bilaterally, smooth, without masses. Epididymis nontender.
The rectal exam was deferred
Musculoskeletal: Upon inspection, the alignment of the major joints and spine is symmetrical. There are no deformities or misalignment of bones. There are no ecchymosis, erythema, lacerations, subcutaneous nodules, or signs of muscle atrophy. Upon palpation there is no edema, effusions, temperature changes, tenderness or crepitus. The boney landmarks are normal and there is physiologic continuity of the anatomic structures. Range of motion testing reveals no restriction or instability related to ligamentous laxity. Muscle strength testing is 5/5 in all major muscle groups. Special testing of the joints for range of motion, nerve compression, and joint contracture is within normal limits.
Neurological: Cranial Nerves 2-12 were tested and are grossly intact. The deep tendon reflexes of the in upper and lower extremities are symmetrical; they are graded at 2/4. Plantar reflexes (Babinski): toes are downgoing. Cerebellar function is normal; Romberg’s test is negative. The gait is normal. Sensory testing for pain (pinprick), light touch, position, and vibration is intact.
Psychiatric: The patient is oriented to person, place, and time. Speech is fluent and words are clear. Thought processes are coherent, insight is good. There are no obsessive, compulsive, phobic or delusional thoughts; there are no illusions or hallucinations. Serial 7s accurate; recent and remote memory intact. The patient’s fund of knowledge: awareness of current events and past history is appropriate for age. The patient’s higher cognitive functions are intact; the patient can perform simple calculations and understands proverbs. The patient’s mood is neutral and the affect appropriate; there are no loose associations.
Skin: Clean, warm and dry without sores or bruises. No suspicious nevi, no bruises or ecchymosis, no alopecia or desquamated lesions. No signs of infections.
Hair: Normal distribution according to the gender. No hair loss in the lower extremities was observed.
Nails: Pink with normal appearance. No clubbing of the finger nails. No onychomycosis.
1. Chronic obstructive pulmonary disease with (acute) exacerbation (J44.1) World Health
Organization (WHO), defines an exacerbation of chronic obstructive pulmonary disease
(COPD) as “an acute event characterized by a worsening of the patient’s respiratory symptoms
that is beyond normal day-to-day variations and leads to a change in medication”. This generally
includes an acute change in one or more of the following cardinal symptoms: Cough increases in
frequency and severity, sputum production increases in volume and/or changes character,
2. Nicotine dependence, cigarettes, uncomplicated (F17.210) Patient is a current heavy smoker, 2 packs of cigarettes daily for more than 20 years.
1. Heart failure: Patient presents with exercise intolerance, unintentional weight loss, refractory volume overload, as well as hypotension and signs of inadequate perfusion (eg, low pulse pressure). Congestive heart failure (CHF) may produce wheezing. A history of orthopnea and paroxysmal nocturnal dyspnea, fine basal crackles on chest auscultation, and typical findings on chest radiographs can lead to the diagnosis of CHF.
2. Pulmonary thromboembolism: The most common presenting symptom is dyspnea followed by the abrupt onset of chest pain (classically pleuritic in nature), cough, and symptoms of deep venous thrombosis. Hemoptysis is an unusual presenting symptom. Rarely do patients present with shock, arrhythmia, or syncope.
3. Community Acquired Pneumonia: On physical examination, approximately 80 percent are febrile, although this finding is frequently absent in older patients, and temperature may be deceptively low in the morning due to normal diurnal variation. A respiratory rate above 24 breaths/minute is noted in 45 to 70 percent of patients and may be the most sensitive sign in older adult patients; tachycardia is also common. Chest examination reveals audible crackles in most patients. Signs of consolidation, such as decreased or bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony are present in approximately one-third
This is a well-known patient which comes this time with mild symptoms of COPD exacerbation. The treatment will be based on oral Antibiotic , continue with routine bronchodilator as usual, steroid inhaled was add and symptomatic treatment of headache and fever. General education about smoking cessation, regarding disease progression, complications, warning signs of respiratory failure, and general laboratory and radiologic tests will also be part of the management.
-CBC with differential.
-Ventolin HFA (Albuterol) Aerosol metered-dose inhaler 90mcg (base)/actuation: 180 mcg (2 puffs) inhaled PO q4-6hr, PRN for SOB
-Prednisone 40 mg 1 tab PO QD x 7 days
-Azithromycin (250 mg) 2 tab PO x 1, then 1 tab PO Q 24 hours x 4 days
-Tylenol 500mg 1 tab PO q6 hrs. PRN, for fever or pain (OTC)
Patient was instructed regarding general measures:
1. Increased fluid intake (minimum 2 L/day).
2. Smoking cessation.
3. Avoid exposure to dust or other airway irritants.
4. Healthy eating
5. Proper resting/exercise Routine
6. Updated Immunization to Avoid disease exacerbation ( Flu Vaccine every season)
Patient was counseling about the dangerous effect of smoking habits in his health conditions. Smoking cessation in this moment was advised. We recommended incorporate to some counseling group for smoking cessation and asking help in BeTobaccoFree.gov or Smokefree.gov.
Follow-up in 3 days to review lab studies results and treatment effectiveness. Also, the patient was instruct to return/go to ER /Notify if the symptoms get worse or notice any new abnormal s/s.
Codina Leik, T. M. (2018). Family Nurse Practitioner Certification Intensive Review. New York: Springer.
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. http://www.goldcopd.org (Accessed on February 13, 2018.
Howcroft M, Walters EH, Wood-Baker R, Walters JA. Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016; 12:CD005074.
Wedzicha JA Ers Co-Chair, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2017; 49.