Assignment 1: Episodic SOAP Note – Persistent Cough

Assignment 1: Episodic SOAP Note – Persistent Cough

Assignment 1: Episodic SOAP Note – Persistent Cough

Patient Information: Patient Initials: B. N     Age: 28       Gender: Male       Race:

SUBJECTIVE DATA:

CHIEF COMPLAINT (CC): “I have been coughing persistently for a week now.”

History of Present Illness (HPI): B.N is a 28-year-old male who came to the hospital complaining of a persistent cough that had lasted for a week. He claims that the cough has worsened his asthma symptoms. The patient claims that he has been waking up in the middle of the night with shortness of breath and in need of treatment for the past few days. He reports that he has recently been using his inhaler almost around the clock. The patient also complains of additional symptoms of running nose and sneezing. He also reports of having taken 1-hour nebulizer treatment the night before her present visit. He is also depressed as a result of losing 3 friends to gun violence in the past. Patient history of present illness is as follows:

PERSISTENT COUGH:

Location: Chest, head, and neck.

Onset: 1 week ago

Character: Arching

Associated signs and symptoms: running nose and sneezing

Timing: Almost around the clock

Exacerbating/ relieving factors: Inhaler which helps with shortness of breath.

Severity: Constant

CURRENT MEDICATIONS:

Acute asthma exacerbation:

PRECEPTOR’S INITIALS_______

• Flonase sprays for running nose and sneezing.
• Breo Ellipta inhalation
• Singulair 10 mg Oral Daily
• Claritin 10mg Oral daily
• Bromfed
• Albuterol

Assignment 1: Episodic SOAP Note – Persistent Cough

ALLERGIES: Penicillin, Seasonal allergies

PMHx (Passed Medical History):

Asthma: Y

Post-traumatic stress disorder: Y

Surgical History: None that is known of.

SOCIAL HISTORY:

Hobbies: Daily marijuana smoker. Denies taking alcohol.

Family Status: no spouse

Diet: NAS

General stress level: High

Smoking Status: Daily marijuana smoker.

Alcohol intake: none

Home Environment: Violent, as he reports having lost 3 friends in the past to gun violence.

FAMILY HISTORY:

Father: CVA

Mother: Breast cancer

PRECEPTOR’S INITIALS_______

Hyperthyroidism

Brother: Lt eye Blindness

Sister: None

Children: None

ROS (Review of Systems):

GENERAL: No weight change, generally healthy, no change in strength or exercise tolerance.

HEAD: Headaches during coughing spells, no vertigo, no injury.

Eyes: Normal vision

ENMT: Ears: No change in hearing, no tinnitus, no vertigo. Nose: No epistaxis, no discharge. Mouth: No dental difficulties, no gingival bleeding, no use of dentures. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged.

NECK: No stiffness, no pain, no tenderness, no noted masses.

CHEST: Shortness of breath, productive cough, reports no wheezing. Taking more rescue inhalers more than usual. The patient states his inhalers about every 2 hours while awake. States he is awakened from his sleep unable to breathe and needing nebulizer treatment.

CARDIOVASCULAR: No chest pains, no palpitations, no syncope, no orthopnea.

ABDOMEN: No change in appetite, no abdominal pains, no bowel habit changes.

GASTROINTESTINAL: no nausea; no vomiting; not vomiting blood; no regurgitation;

GENITOURINARY: No urinary urgency, no dysuria, no change in the nature of urine.

HEMATOLOGIC: No bleeding, bruises or anemia.

LYMPHATICS: No history of splenomegaly or enlarged nodes

ENDOCRINOLOGIC: No changes in hair or skin, polydipsia, denies polyuria or polyphagia.

PRECEPTOR’S INITIALS_______

MUSCULOSKELETAL: No pain in muscles or joints, no limitation of range of motion, no paresthesia or numbness.

NEUROLOGIC: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.

SKIN: no rash, lesions, nodules, ulcer, induration, jaundice, abnormal nevi and good turgor.

PSYCHIATRIC: Patient states he was diagnosed with PTSD in August 2018. Pt states he has seen 3 friends die in his presence. Pt reports not following up after the diagnosis. He has been self-medicating with marijuana. Denies suicidal thoughts.

OBJECTIVE DATA

PHYSICAL EXAM:

The patient is a 28-year-old male.

Vital signs:

Constitutional:

General Appearance: The patient appears healthy, well-nourished, with no signs of acute distress.

HEAD: Normocephalic with rashes noted on the posterior left side.

EYES: PERRLA, conjunctivae clear, EOM’s full. EARS: EAC’s clear, TM’s normal.

NOSE: Boggy mucosa, swollen, and reddened left nostril.

THROAT: Reddened mucosa.

NECK: Supple, no masses, no thyromegaly, no bruits.

CHEST: Inspiratory wheezing.

HEART: RR, no murmurs, no rubs, no gallops.

GASTROINTESTINAL: Soft, no tenderness, no masses, BS normal.

PRECEPTOR’S INITIALS_______

GENITOURINARY: Deferred.

RECTAL: Deferred

BACK: Normal curvature, no tenderness.

NEURO: Physiological, no localizing findings.

SKIN: Normal, no rashes, no lesions noted.

PROSTATE: Deferred

EXTREMITIES: Warm, well perfused, no edema.

LYMPHATIC: no enlargement of cervical nodes; no axillary adenopathy; no inguinal adenopathy;

MUSCULOSKELETAL: digits/nails: no clubbing, cyanosis, or evidence of ischemia or infection; symmetrical enlargement of wrists, knees, ankles. Neck, shoulder, rt hip and bilk no pain.

PSYCHIATRIC: mental status is alert and oriented x3.

Assignment 1: Episodic SOAP Note – Persistent Cough

DIAGNOSTIC RESULTS: Recommended test to take:

• Imaging scans: Chest X-ray
• EKG

ASSESSMENT/PLAN:

• (J45.909) Unspecified asthma, uncomplicated: This is a chronic respiratory disease in which the bronchial airways become swollen and narrowed making breathing difficult (Erjefält, 2019). The patient is positive for shortness of breath, persistent coughing and wheezing. other symptoms include rapid breathing and tightness.
• (R05) Cough: This is a disorder that is characterized by sudden, often persistent, and

PRECEPTOR’S INITIALS_______

spasmodic contraction of the thoracic cavity, leading to the violent release of air from the lungs, usually accompanied by a distinctive sound (Carroll, 2019). The patient complained of having a persistent cough for about 1 week.

• (J30.9) Allergic rhinitis, unspecified: This is a disorder that is characterized by nasal mucosa inflammation caused by an IgE-mediated response specifically to external allergens (Maniscalco et al., 2018). It is characterized by symptoms such as sneezing and running nose of which are positive for the patient in this case (Mahmoudi, 2016). Other symptoms include nasal congestion, rhinorrhea, itching, drowsiness, fatigue, and malaise.

PLAN AND PREVENTION:

For the management of symptoms and controlling the patient’s asthmatic condition, the following drugs are recommended (McCracken, 2017):

• Albuterol Sulfate (Proventil HFA) 108 (90 Base) MCG/ACT Inhalation Aerosol Solution Sig: 2 puffs inhaled orally every 4 hours as needed
• Fluticasone Furoate-Vilanterol (Breo Ellipta) 100-25 MCG/INH Inhalation Aerosol Powder Breath Activated Sig: 1 puff inhaled orally daily
• Loratadine (Claritin) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth daily
• Montelukast Sodium (Singulair) 10 MG Oral Tablet Sig: Take 1 tablet (10 mg) by mouth daily
• Pseudoephed-Bromphen-DM (Bromfed DM) 30-2-10 MG/5ML Oral Syrup Sig: 10 ml orally every 4 hours as needed

PRECEPTOR’S INITIALS_______

For the psychological health of the patient, the following are recommended:

• Increase the intake of fruits and vegetables. Cut down on fried foods and avoid greasy foods. Consume mainly baked or boiled foods.
• Avoid secondhand smoking.
• Exercise frequently for about 30 minutes a day or 1 hour for four days in a week. Good physical activities include walking, dancing, pedaling stationary bikes, and walking in one spot at home (Horak et al., 2016).

Follow up: Return to the clinic after two weeks for evaluation of the treatment plan.

REFLECTION NOTES:

The evaluation of the patients presenting illness has been done appropriately. However, in such a case, I would recommend additional diagnostic tests such as complete white blood cell count to rule out infection and culture of the nasal secretion to find out whether the symptoms are as a result of a bacterial or viral infection (Cisneros et al., 2015). I would then choose the best treatment plan after confirmation of the lab results.

 

PRECEPTOR’S INITIALS_______

References

In Carroll, T. L. (2019). Chronic cough. San Diego, CA: LOGO Plural Publishing.

Mahmoudi, M., & In Mahmoudi, M. (2016). Allergy and Asthma: Practical Diagnosis and Management. Cham Springer International Publishing Imprint: Springer.

Erjefält, J. S. (January 01, 2019). Unravelling the complexity of tissue inflammation in uncontrolled and severe asthma. Current Opinion in Pulmonary Medicine, 25, 1, 79-86.

Cisneros, S. C., Melero, M. C., Almonacid, S. C., Perpiñá, T. M., Picado, V. C., Martínez, M. E., Pérez, . L. L., … García, H. G. (May 01, 2015). Guidelines for Severe Uncontrolled Asthma. Archivos De Bronconeumología (english Edition), 51, 5, 235-246.

McCracken, J. L. (January 01, 2017). Diagnosis and Management of Asthma in Adults: A Review. Jama, 318, 3, 279-279.

Maniscalco, M., Molino, A., Carone, M., Ruggeri, P., Caramori, G., Paris, D., Melck, D. J., … Motta, A. (March 01, 2018). Differential diagnosis between newly diagnosed asthma and COPD using exhaled breath condensate metabolomics: A pilot study.

Horak, F., Doberer, D., Eber, E., Horak, E., Pohl, W., Riedler, J., Szépfalusi, Z., … Studnicka, M. (January 01, 2016). Diagnosis and management of asthma – Statement on the 2015 GINA Guidelines. Wiener Klinische Wochenschrift, 128, 541-554.

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Preceptor”s Signature and Date                                                          Student’s Signature and Date