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Soap Note Assignment: Bacterial Pneumonia

Soap Note Assignment: Bacterial Pneumonia

 

Name: J.P                   Age: 35 years              Sex: Female                Date: 12-07-2019

Chief Complaint:  “I have been having chest pain and a cough in the past eight days with production of rusty sputum which clogs my airways causing grunting. Four days ago, I started experiencing difficulty in breathing with an increased body temperature, which has progressed over time.”

History of Present Illness: The patient states that she started experiencing chest pain with a productive cough eight days ago. The chest pain lasts for about 5 minutes and occurs when coughing or engaging in vigorous activity. She describes the pain as pleuritic and moderate with a pain scale of 4/10; it is localized to the sternum and does not radiate to the arms or the back. The pain is aggravated by cough and activity and is relieved partly by rest. She reports taking expectorant cough syrup to relieve cough, which had a slight impact. States that the difficulty in breathing when performing activities have negatively impacted her daily activities.

Past Medical History: Diagnosed with Asthma at the age of 5 years, but reports having no asthma exacerbations for the past 20 years. No history of other chronic diseases. She was admitted at the age of 7 years from an asthma exacerbation. Reports being fully immunized as per the immunization schedule. Reports history of occasional flu and colds. She denies having a history of pneumonia, TB, or cardiac disease. No history of gynecological conditions and sexually transmitted infections. She denies a history of psychiatric disorders. Reports performing a monthly self-breast exam, last Pap smear was five months ago. No history of radiography or diagnostic procedures. No history of psychiatric disorders or admission.

Past Surgical History: Denies having a history of major trauma, or fractures. No history of minor or major surgeries.

Family History: She is the 3rd born in a family of 4. Mother has Type 1 Diabetes mellitus, diagnosed at 32. Father died at 56 years out of a road traffic accident. The firstborn sibling had Type 1 diabetes diagnosed at 35, 4th born sibling has a history of Asthma. Maternal grandfather had Hypertension and Type 1 diabetes mellitus and died from a stroke at 78 years. No history of cancer in the family.

Personal and Social History: She is married and has two children, a boy, and a girl. She currently lives with her husband and children in an uptown neighborhood. She has a university degree and is currently pursuing a postgraduate degree in Economics. She is Catholic and attends church masses at least twice in a month. Reports that she enjoys going to museums and painting during her leisure time. Denies having a daily exercise program but reports going to the gym and swimming once a week. Reports taking about four cans of beer on weekends but denies smoking or using illicit drugs. States that she consume lots of coffee and often have headaches if she does not drink coffee. Reports taking a balanced diet with lots of vegetables and fruits and takes about five glasses of water in a day. She sleeps for approximately 7 hours a day with no naps during the day.

Allergies: Reports being allergic to dust mites, which causes sneezing and rhinorrhea. No known food or drug allergies.

Medication: Currently on an OTC expectorant cough syrup 10 mls TDS to alleviate cough symptoms.

Review of Systems

General: Reports frequent fatigue, high body temperatures, and chills. Denies weight loss.

Skin: Denies skin color changes, itching, cracking of the skin, rashes, moles, or sores. She denies any changes in the appearance of hair and nails.

HEENT: Head: Reports frequent headaches, denies a history of head trauma. Eyes: Denies eye pain, itching, redness, decreased vision, excessive tearing, blurred, or double vision. No history of eye injuries, cataracts, or glaucoma. Ears: Denies hearing loss or difficulties, ear pain, discharge, tinnitus, pain behind the ear, or history of ear infections. Nose and sinuses: Reports thick nasal discharge and occasional colds and flu; denies nose bleeding. Throat: Denies tooth pain, sore tongues, bleeding gums, and tooth cavities. Last dental check-up 11 months ago. Denies difficulty in swallowing, and voice hoarseness.

Neck: Denies neck stiffness, pain, or history of Goiter.

Breast: Denies breast pain, tenderness, or presence of palpable lumps or masses. Performs monthly breast exams.

Respiratory: Reports cough with thick yellow sputum production. Reports difficulty in breathing, chest pain, and grunting. Denies wheeze or blood in sputum. Has a history of asthma. No history of TB, pneumonia, or COPD.

Cardiovascular: Reports localized chest pain. Denies having heart palpitations, edema, and distended neck veins. She has no history of hypertension or cardiac diseases.

Gastrointestinal: Reports loss of appetite. Denies nausea, vomiting, epigastric pain, abdominal pain, bloating, diarrhea, constipation, or rectal bleeding.

Peripheral vascular: Denies calf muscles pain or tenderness, varicose veins, or history of DVT.

Genitourinary: Menarche at 13 years, reports regular and normal menstrual flow. Denies pelvic pain, abnormal vaginal discharge, vaginal itching, and sores. Denies increased urinary frequency and urgency, incontinence, polyuria, oliguria, nocturia, or dysuria. No history of UTIs or kidney diseases. Date of last menstrual period- 1st-Aug-2019. Reports being sexually active and use combined oral contraceptives.

Musculoskeletal: Denies muscle, neck, or back pain. Denies joint stiffness, pain swelling, tenderness, or limited joint activity.

 Neurologic: Reports frequent headaches. Denies tingling sensations, tremors, seizures, dizziness, blackouts, or fainting.

Psychiatry: Denies having suicidal thoughts or attempts. Denies history of anxiety disorders, depression, psychosis, or psychiatric admission.

Physical Examination

Vital signs: BP- 124/84; Temp- 38.6; Resp- 26 Pulse- 118

Height: 5’4 ft.,                       Weight: 158 pounds   BMI: 27.1

General: Sick-looking adult female patient in no acute distress. Well-groomed and appropriately dressed. Alert and oriented x3.

Skin: Skin is brown, hot, and dry. No discoloration, rashes, lesions, or bruises noted. Hair is black and well distributed.

HEENT: Head: Symmetrical, normocephalic with no lesions. Eyes: No excessive lacrimation, or conjunctiva injection. The sclera is

Soap Note Assignment Bacterial Pneumonia

Soap Note Assignment Bacterial Pneumonia

white, and the conjunctiva is pink. Ears: Ear wax present; tympanic membranes non-inflamed and intact. No ear discharge or mastoid bone tenderness noted. Nose: Presence of thick mucus. Nasal flaring present. The nasal septum is well-aligned. Throat: Lips are moist and pink. No halitosis, tooth cavity or missing tooth noted. Pharynx and Tonsillar gland non-inflamed with no exudate. Neck: Symmetrical with tracheal deviation. Thyroid gland normal.

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Respiratory: No thoracic cavity deformities noted. Labored respiration with use of accessory muscles. On auscultation, faint breath sounds, and crackles, rhonchi, and pleural friction rub are present. Lungs dull on percussion.

Cardiovascular: S1 and S2 loud at the apex. No edema, S gallop, JVD, heart murmurs, or carotid bruits present.

Gastrointestinal: Abdomen is round with no scars. Bowel sounds active in all quadrants. No tenderness, masses, tumors or organomegaly on palpation. No CVA tenderness.

Genitourinary: Non-distended urinary bladder. Normal vaginal discharge with no perineal sores or scars.

Musculoskeletal: Normal gait and posture. The spine is well-aligned with no skeletal deformities. No joint tenderness, pain, swelling, or deformities. Muscle strength 5/5. Full ROM.

Neurological: Clear speech with a normal tone. Cranial nerves intact and reflexes present. Normal gait, posture, and stable balance. Normal muscle bulk and tone.

Psychiatric: Appropriately dressed and neat. Coherent thought process and no disorganized speech. No hallucinations, delusions or thought ideations present.

Diagnostic Tests: 

  1. Blood culture- pending
  2. Chest X-ray- Bilateral and multilobal infiltrate present

Identified problems: Productive cough, fatigue, fever, tachypnea, tachycardia, and labored respiration, use of accessory muscles, adventitious breath sounds, and dullness on percussion, pleural friction rub, and tracheal deviation.

Differential diagnosis: 

Acute COPD ICD 10- J44. 1: Positive findings of acute COPD include productive cough, dyspnea, and use of accessory muscles, adventitious breath sounds, and fatigue.

Pulmonary Tuberculosis ICD 10- A15. 0: Positive findings of Pulmonary TB include productive cough, chest pain, chills, fever, and fatigue.

Bronchiolitis ICD 10- J21. 9Positive findings include tachypnea, fever, tachycardia, adventitious breath sounds, and use of accessory muscles.

Final diagnosis: Bacterial pneumonia ICD 10: J15. 9

Bacterial pneumonia results from a lung infection by a pathogen, and its hallmark symptom is productive cough with sputum. Common pathogens that cause bacterial pneumonia include streptococcus pneumonia, pseudomonas, klebsiella, pneumococcal, haemophillus, and anaerobic species (Grousd, Rich & Alcorn, 2019). Clinical signs include central cyanosis, tachycardia, and tachypnea, use of respiratory accessory muscles, hyperthermia, and altered mental status (Waites et al., 2017). Physical findings include nasal flaring, decreased intensity of breath sounds, tracheal deviation, crackles, rales, lymphadenopathy, dullness on percussion, and pleural friction rub (Bickley & Szilagyi, 2017). Positive findings of Bacterial pneumonia in this patient include productive cough, fever, nasal flaring, tachypnea, tachycardia, labored respiration, adventitious breath sounds, dullness on percussion, and tracheal deviation.

Treatment Plan

Further diagnostic tests: Sputum culture within 6 hours to guide therapy and rule out Pulmonary TB (Grousd, Rich & Alcorn, 2019).

Medication: Augmentin 625 mg BD for 10 days.

Broncotron D syrup 10 ml PO QID to expel sputum and suppress cough.

Non-pharmacologic Therapy: Propping the patient to maintain a patent airway and enhance adequate chest expansion during respiration (Brook, 2016).

Oxygen therapy to promote adequate tissue perfusion.

Suctioning of secretions to maintain a patent airway (Grousd, Rich & Alcorn, 2019).

Maintain hand hygiene to prevent future respiratory infections.

Monitoring of vital signs

Health education: Adhere to antibiotic drug regimen to avoid bacteria resistance.

Cough hygiene and dispose sputum properly to avoid infecting others.

Practice hand hygiene to prevent future infections.

Engage in daily physical activity to maintain a healthy weight and boost the immune system (Brook, 2016).

Referral: Referral to a pulmonologist if symptoms persist.

Follow-up:  A scheduled follow-up in the outpatient clinic two weeks after discharge to monitor progress and assess potential respiratory complications. The patient will be advised to seek immediate medical care if symptoms persist or worsen, including difficulty in breathing, excessive fatigue, or blue discoloration.

Self-Reflection: In this assessment, I took a comprehensive patient history and physical examination individually with no much challenges. I was able to identify the abnormal findings and interpret them without assistance from my senior colleagues and instructors. I have noticed a significant improvement since my previous assessment. My objective is to increase my knowledge in pharmacology of the respiratory system and the prescription of drugs.

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