[Solved] Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past

Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past

For your case study, use the following case to complete a focused SOAP note. Make sure to answer all the questions at the end of your SOAP note and follow the rubric for the required elements in this case. Add information as necessary to create a cohesive soap note.

Use the following case to complete a focused SOAP note:

Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past two days, he has started coughing up thick pale-yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse.

He has also felt very tired. He has taken Tylenol off and on and it does help slightly. About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.

PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.

Medications:  lisinopril 20 mg daily; metformin 500 mg twice daily

Allergies:  Penicillin

Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.

Vitals:  Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%

The questions below need to be answered at the end of the SOAP Note.

You can make up patient information that is not given in the case study.

Please document the questions after you write your SOAP note

1. Please document the history questions you would ask the patient. What questions would you ask related to the current complaint? What questions would you ask related to his comorbidities?
2. What Physical Exam would you obtain? Describe what you would be looking for.
3. What labs/diagnostics would you order?
4. List your top four differential diagnoses. Explain your rationale for your top diagnosis.
5. What is a CURB Score?
6. When his labs come back, his CMP shows that his BUN is 21. Based on that information and on his presentation, what is his CURB score and how did you arrive at that score?
7. Based on his CURB score, should he be treated on an outpatient or inpatient basis?
8. His chest x-ray does indeed show infiltrates. What would be your treatment plan forhim?
9. Name 3 health promotion topics that you should discuss with him.
10. What would your follow-up plan be?

Use the Focused SOAP Note Template to address the following:

• Subjective: What details are provided regarding the patient’s personal and medical history?
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
• Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
• Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: Describe your “aha!” moments from analyzing this case.

Expert Answer and Explanation

Focused SOAP Note

Patient Information:

Lou Brown, a 58-year-old, male, white

S.

CC: “Intermittent cough for the past four days”.

HPI: Lou Brown is a 58-year-old white male who came to the hospital complaining of a cough for the past four days. The patient noted that the cough started as a dry cough. However, for the past two days, the cough has been producing thick pale-yellow phlegm. The cough is intermittent. Associated signs include tiredness, weakness, and fever. The cough started after playing poker with one of his friends who were sick one and a half week ago.

The cough worsens after smoking and this has prevented him from smoking in the past few days. He took Tylenol and has not helped improve his cough. The severity of the cough is on a scale of 8/10

Current Medications: Metformin 500 mg twice daily to treat type two diabetes; lisinopril 20 mg daily to treat hypertension.

Allergies: Penicillin

PMHx: History of type two diabetes and hypertension. Has not received pneumonia vaccine. No Covid-19 vaccine. No tetanus vaccine.

Soc & Substance Hx: Smokes 40 packs of cigarettes a year. No drugs or alcohol. He has a master’s level education. Works at the federal government as an accountant. He is married with two children. He does not have any specific diet.

Fam Hx: His fathered died of stroke and mother of heart attack.

Surgical Hx: No past surgical procedures.

Mental Hx: No history of mental health disorders.

Violence Hx: No history of violence or traumatic events. No safety concerns at home.

Reproductive Hx: Is sexually active. Engages in vaginal sex. No sexual concerns.

ROS:

• GENERAL: No chills or weight loss.
• HEENT: Eyes: No yellow sclerae, no double vision, visual loss, or blurred vision. Ears, Nose, Throat: No sneezing, sore throat, hearing loss, or congestion.
• SKIN: No rash.
• CARDIOVASCULAR: No edema, chest pain, or chest pressure. No chest discomfort.
• RESPIRATORY: Reports coughing that produces phlegm. No shortness of breath.
• GASTROINTESTINAL: No abdominal blood or pain. No diarrhea, vomiting, or anorexia.
• GENITOURINARY: No urge to urinate. No burning on urination.
• NEUROLOGICAL: No ataxia, dizziness, headache, tingling, or numbness in the extremities. No changes in bladder or bowel control. No confusion.
• MUSCULOSKELETAL: No stiffness, back pain, or muscle pain.
• HEMATOLOGIC: No bleeding, anemia, or bruising.
• LYMPHATICS: No history of splenectomy. No enlarged nodes.
• PSYCHIATRIC: No history of mental health problems.
• ENDOCRINOLOGIC: No polydipsia, no reports of cold, heat intolerance, or sweating.
• REPRODUCTIVE: Sexually active.
• ALLERGIES: Reports penicillin allergy.

O.

Physical exam:

• Vital Signs:  150/94, Wt. 190 lbs, Ht. 5’4”, Temp: 101.0 orally, R 26, P 88, Pulse ox 96%.
• Constitutional: Speech coherent and clear. Gait has no deviations. The patient is oriented and attentive x 4. Eye contact is good. He answers questions properly. He was properly dressed for the occasion and weather and was cooperative during the interview.
• Cardiovascular: Regular rhythm and rate. No chest deformities or abnormalities on inspection. No thrills, vibration, or pulsation, or murmur on palpation. Normal blood flow to the extremities. No edema.
• Respiratory: Breathes using accessory muscles, shallow breathing, and skin is pale on inspection. Chest pain on palpation, when taking deep breaths. Chest x-ray shows infiltrates. Lungs have crackled and sound coarse on auscultation. Decreased breath sounds in the right lower lobe on auscultation. Fluids in the lungs on percussion.

Diagnostic results:

• Blood Urea Nitrogen (BUN) Test: The test is used to assess hydration status and kidney function. The results of the test can help healthcare professionals identify the severity of the infection and whether it warrants hospitalization (Cohen et al., 2020). The test shows that the patient’s BUN level is 21.
• Chest X-ray: Nahvi et al. (2019) noted that a chest X-ray helps in evaluating the severity of the infection and confirming the diagnosis of pneumonia. Chest X-ray shows infiltrates.

A.

Differential Diagnoses:

Community-Acquired Pneumonia: Community-acquired pneumonia is the primary diagnosis for this case. The symptoms of pneumonia include changes in mental status or confusion, especially in older adults, fatigue and tiredness, fever (high or mild), chest discomfort or pain, especially when taking a deep breath or coughing, cough that produces mucus, or phlegm, sweats, and chills, and difficulty breathing or shortness of breath (Hayes & Talbot, 2019).

A patient with pneumonia might also record a loss of appetite. The patient has symptoms such as fever, cough that produces phlegm, and shortness of breath which are consistent with pneumonia, making the disease the primary diagnosis. The disease is also a primary diagnosis because chest X-ray shows infiltrates, there is fluid in the lungs, chest pain on palpation, and lungs have crackles (Hayes & Talbot, 2019).

Acute Bronchitis: The second diagnosis is acute bronchitis. Acute bronchitis is the swelling of the bronchial tubes that causes the production of phlegm, intermittent coughing, and shortness of breath and is usually caused by a virus (Hasegawa et al., 2020). The disease has been included in the diagnosis because the patient has all three symptoms. However, the disease has been ruled out because the patient presents with pale-yellow phlegm for the past two days which suggests a bacterial infection. Also, the patient has type two diabetes and hypertension which increase his risks of developing a bacterial infection. Therefore, the patient risks developing bacterial pneumonia more than bronchitis.

Chronic Obstructive Pulmonary Disease (COPD): The third diagnosis is COPD. COPD is a chronic respiratory disease characterized by shortness of breath, chest tightness, persistent cough, and wheezing (Hill et al., 2019). The disorder has been included in the diagnosis because the patient experiences shortness of breath and intermittent coughing. He also smokes cigarettes and this puts him at risk of developing COPD. The disease is usually diagnosed in people with a long history of smoking (Hill et al., 2019). However, the disease has been ruled out because the patient does not have chronic respiratory symptoms such as wheezing, or progressive dyspnea. The X-ray also supports the presence of pneumonia rather than COPD, making it a secondary diagnosis.

Asthma: The last diagnosis is asthma. Asthma is a chronic respiratory disease-causing narrowing and swelling of the airways, leading to shortness of breath, wheezing, and coughing (Dodd et al., 2020). The disease has been included because the patient experienced coughing and shortness of breath. However, it was ruled out because of the patient’s history and presenting symptoms. The patient’s symptoms of fever, cough with sputum production, fatigue, and infiltrates in the chest are more indicative of acute respiratory infections such as pneumonia. Additionally, asthma has been ruled out because the patient’s social and medical history does not suggest a significant history of asthma.

Though presenting history, subjective data, and diagnostic tests show that the patient has pneumonia, complete blood count (CBC), sputum culture and sensitivity test, blood culture test, arterial blood gas (ABG), electrocardiogram (ECG), and urinalysis should be obtained to improve the diagnosis decision. The patient should be referred to a pulmonologist.

Therapeutic Intervention 

The patient is recommended to start azithromycin 500 mg once by mouth daily for 7 days. Tsalik et al. (2022) conducted a randomized, placebo-controlled, double-blind, non-inferiority trial in five healthcare hospitals in the US and found that azithromycin is an effective treatment for pneumonia. He should also be advised to continue taking Tylenol to improve pain and fever. The patient should be advised to be treated on an inpatient basis based on his CURB-65 score and his medical history. The patient has a CURB-65 score of 2.

He meets two criteria including a BUN level of more than 20 and a respiratory rate of 26, and as such he would benefit from intensive treatment as an inpatient patient. His chest X-ray findings and vital signs also support the need for hospitalization.

Education 

He should be advised to stop smoking because it puts him at risk of many respiratory diseases. He should be referred to a therapist to start smoking cessation counseling. Quitting smoking can greatly reduce his risk of respiratory infections (Tsalik et al., 2022). He should also be educated to get vaccinated against influenza and pneumococcal. He should also be educated to undergo regular check-ups to monitor any complications and manage chronic conditions.

Follow-Up Visits 

Follow-up for the patient will depend on how he responds to treatment and his health status. He should come back to the hospital seven days after finishing his antibiotic dose for a check-up and to monitor his health.

Reflection 

This case highlights the significance of accurately diagnosing and treating pneumonia, especially in people with risk factors such as a history of chronic conditions and smoking. The case also emphasizes the importance of azithromycin for community-acquired pneumonia. Health providers need to consider all possible diagnoses when handling a case and rule out other conditions. I agree with the preceptor’s diagnosis and treatment for the patient because it is supported by peer-reviewed data. If given a chance again, I would educate the patient about the importance of finishing his medications as prescribed to prevent antibiotic resistance. Health promotion would involve educating the patient to stop smoking.

References

Cohen, J., Akram, F., Shakoor, S., Tabatabai, A., & Tahir, F. (2020). The predictive value of blood urea nitrogen levels in community-acquired pneumonia. Cureus, 12(4), e7674. https://doi.org/10.7759/cureus.7674

Dodd, K. E., Wood, J., & Mazurek, J. M. (2020). Mortality among persons with both asthma and chronic obstructive pulmonary disease aged ≥25 years, by industry and occupation – United States, 1999-2016. MMWR. Morbidity And Mortality Weekly Report, 69(22), 670–679. https://doi.org/10.15585/mmwr.mm6922a3

Hasegawa, K., Linnemann, R. W., Avlamov, V., Feldman, C., Ueda, P., & Camargo, C. A. Jr. (2020). Association of acute bronchitis with exacerbation of underlying asthma: A nationwide cohort study. Annals of Allergy, Asthma & Immunology, 124(1), 52-57. https://doi.org/10.1016/j.anai.2019.10.003

Hayes, M., & Talbot, T. (2019). Symptom management of pneumonia. American Journal Of Respiratory And Critical Care Medicine, 199(6), P15-P16. doi: 10.1164/rccm.1996P15

Hill, K., Goldstein, R., Guyatt, G. H., Blouin, M., Tan, W. C., Davis, L. L., & Jones, P. W. (2019). Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. American Journal of Respiratory and Critical Care Medicine, 200(8), 863-872. doi: 10.1164/rccm.201811-2117OC

Nahvi, M., MacMahon, P. J., & Leeper, K. V. (2019). Chest radiography for pneumonia in outpatients: A systematic review and meta-analysis. American Journal of Medicine, 132(10), 1192-1203. doi: 10.1016/j.amjmed.2019.05.007

Tsalik, E. L., Rouphael, N. G., Sadikot, R. T., Rodriguez-Barradas, M. C., McClain, M. T., Wilkins, D. M., & Zeng, L. (2022). Efficacy and safety of azithromycin versus placebo to treat lower respiratory tract infections associated with low procalcitonin: A randomised, placebo-controlled, double-blind, non-inferiority trial. The Lancet Infectious Diseases. https://doi.org/10.1016/S1473-3099(22)00735-6

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