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This 60-year old male presented to the emergency room with fever, chest pain, shortness of breath, and increased heart rate. He has a history of COPD, alcohol abuse, and is a former smoker. On physical exam, he appeared weak with obvious shortness of breath and abnormal lung sounds. Lab work showed signs of infection and pneumonia was diagnosed. The patient was admitted and started on antibiotics and bronchodilators to treat his COPD exacerbation and pneumonia.

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Llosa June
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3K views2 pages

Soap Note

This 60-year old male presented to the emergency room with fever, chest pain, shortness of breath, and increased heart rate. He has a history of COPD, alcohol abuse, and is a former smoker. On physical exam, he appeared weak with obvious shortness of breath and abnormal lung sounds. Lab work showed signs of infection and pneumonia was diagnosed. The patient was admitted and started on antibiotics and bronchodilators to treat his COPD exacerbation and pneumonia.

Uploaded by

Llosa June
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • SOAP Note Introduction
  • Assessment & Plan

SOAP NOTE

Subjective

CC: Fever, severe right-sided chest pain, increasing shortness of breath (SOB), and increased heart rate

HPI: 60 year-old male presented to the ER today after 2 days of increasing malaise, SOB, spiking fevers,
chest pain, rigors, tachycardia, and gastric pain; admitted for pneumonia and acute exacerbation of
COPD

PMH: chronic obstructive pulmonary disease (COPD), shortness of breath (SOB), alcohol withdrawal
seizures, degenerative joint disease (DJD)

SH: Smoked for past 25 years; S/P alcohol abuse; enrolled in Alcoholics Anonymous and has not had a
drink for more than 1 year

FH: Noncontributory

ALLERGIES: Ampicillin (rash) "years ago"

Objective

MEDICATIONS: Phenytoin (400 mg PO qHS), Ipratropium inhaler (2-4 puffs PRN), Metaproterenol
inhaler (2-4 puffs PRN), Prednisone (30 mg PO qD), Acetaminophen (500 mg PO TID PRN)

PHYSICAL EXAM:
GEN: Diaphoretic, agitated, weak-looking man with obvious SOB
VS: BP l4O/90, RR 28, HR 125, T 39.5'C, Wt 65 kg
HEENT: Purulent, rust-colored sputum X 2 days
COR: Normal S1 and S2; no murmurs
CHEST: Prolonged expiratory phase, bilateral rales and rhonchi, RLL dullness
ABD: Gastric pain
GU: WNL
RECT: Guaiac positive
EXT: WNL
NEURO: A and O X 3; appropriate affect, lethargic

LAB TESTS/ SERUM DRUG CONC/ DIAGNOSTIC TESTS:


Na 145 (145)
K 3.7 (3.7)
Cl 101 (101)
HCO3 33 (33)
BUN 59 (21)
Cr 106.1 (1.2)
Hct 0.49 (49)
Hgb 180 (18)
Lkcs 18.6 x 109 (18.6 x 103)
Plts 300 x 109 (300 x 103)
AST 0.67 (40)
ALT 0.53 (32)
Alb 42 (4.2)
Phenytoin 80 (20)
Lkc differential: PMN 0.88 (88%), bands 0.10 (10%), lymphs 0.02 (2%)
ABG (on room air): PO2 70, PCO2 47, pH 7.35
PFTs: FEV1- 60% (pre-B2-agonist), FEV1/FVC- 70% (post- B2-agonist)
Sputum Gram's stain >50 Lkcs/HPF; 0-5 epithelium cells/HPF; gram-positive cocci in pairs (many)
Blood cultures: Pending
Chest x-ray: RLL consolidation consistent with right lower lobe pneumonia

Assessment

COPD (moderate, stage 2) Tobacco use disorder

Plan

Discussed the nature of COPD. Medication management (Bronchodilators, inhaled


corticosteroids/systematic corticosteroids therapy and antibiotics). Referral for pulmonary rehabilitation
exercise program. Discussed importance of risk reduction, including smoking cessation, and offered
medication to assist with smoking cessation. Declines at this time but has strong motivation to quit.
Wants to try slow taper of cigarettes. Avoid vigorous outdoor exertion or stay inside on high-pollution
days. Will evaluate for home oxygen on a routine basis. Administer Influenza and pneumococcal vaccine.

SOAP NOTE Subjective CC: Fever, severe right-sided chest pain, increasing shortness of breath (SOB), and increased heart ra
Plts 300 x 109 (300 x 103) AST 0.67 (40) ALT 0.53 (32) Alb 42 (4.2) Phenytoin 80 (20) Lkc differential: PMN 0.88 (88%),

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