Clinical Case
APC1- Spring 2020
SOAP Note Case #3
Objectives/Instructions:
Draft an INDIVIDUAL SOAP note (Subjective, Objective, Assessment and Plan). Each student will submit a final SOAP within 1 week of class. Discussing the therapeutic thought process and evidence-based decision making in groups during class is permitted.
Clinical Case
Assume you are on APPE rotation at a local emergency department with their pharmacist. You have consulted with the medical team and they confirm the patient is going to be admitted to the hospital. Please write a SOAP note describing the appropriate management for this patient. In your assessment, consider the appropriate treatment setting (e.g. outpatient, inpatient, intensive care unit [ICU]) using relevant scoring tools (CURB-65 and QSOFA preferred, PSI score not desired for this case).
CHIEF COMPLAINT: Shortness of breath and cough.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male with no significant past medical history presenting to the ED. The patient appears confused. He is unable to provide a thorough history. Per the patient’s wife, he has been short of breath and has had a cough. She remembers waking up in the morning the last few days having to change to the sheets because they have been covered in his sweat. She doesn’t believe he has had any antibiotics within the last few months.
REVIEW OF SYSTEMS: Unable to obtain due to patient’s illness.
PAST MEDICAL HISTORY: No significant past medical history.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Does not drink alcohol, does not smoke.
PHYSICAL EXAMINATION:
Vital Signs at 17:05: temperature 99.80F, heart rate is 125bpm, respirations 25 rpm, blood pressure 108/80mmHg, O2 sat 95% on 2 liters. Height: 5’9” Weight: 170lbs (scale)
General: The patient is an ill-appearing male. He is very tachypneic.
HEENT: Head is atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Dry mucous membranes.
Cardiovascular: Tachycardic with no murmurs, rubs or gallops. Peripheral pulses are 2+.
Respiratory: Tachypneic. Crackles heard in the RLL. The patient has some increased work of breathing and is unable to form complete sentences with his breathing.
Extremities: The patient does move his extremities equally. He has no edema, clubbing or cyanosis.
Abdomen: Soft, nontender to palpation, positive bowel sounds.
Psych: The patient is awake and confused. He does attempt to answer questions but again is very tachypneic. Skin is warm and dry without rashes or lesions. A&O x 2
Laboratory Examination at 1726
Lab Value
Normal Range
Value
Units
Na
135-145
139
mEq/L
K
3.4-4.8
4.3
mEq/L
Cl
99-109
100
mEq/L
CO
21-30
29
mEq/L
BUN
7-22
18
mg/dL
SCr
0.8-1.4
1.1
mg/dL
Glu
65-109
109
mg/dL
Ca
8.6-10.3
9.1
mg/dL
WBC Count
(4.0 – 9.0)
14
103/uL
RBC Count
(4.50 – 5.70)
4.49
106/uL
Hemoglobin
(13.6 – 16.7)
13.5
g/dL
Hematocrit
(40.0 – 49.0)
38.8
%
Platelet Count
(130 – 350)
212
103/uL
CHEST X-RAY @ 1710
CLINICAL HISTORY: Shortness of breath.
RESULT: A single portable upright AP view of the chest was obtained and compared to three months prior.
There is airspace opacity in the right lower lobe. The cardiomediastinal contours are within normal limits. No large pleural effusion. No pneumothorax. A well-healed fracture of the proximal diaphysis of the left humerus is identified.
IMPRESSION: Findings compatible with right lower lobe pneumonia in the appropriate clinical setting.
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