Complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week (Gastrointestinal system), and the completed SOAP note should be submitted to the Dropbox. When submitting your note, be sure to include the reference number from eMedley where you entered this specific patient’s case entry.
See the SOAP note template and this example as a reference.
SOAP NOTE R# 4452762
Community acquired Pneumonia symptoms include malaise, chills, rigor, fever, cough, dyspnea, and chest pain. Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates the diaphragm. (merckmanuals.com). Acute respiratory distress syndrome (ARDS) is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event, such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. (Harman, 2016). Emphysema is destruction of lung parenchyma leading to loss of elastic recoil and loss of alveolar septa and radial airway traction, which increases the tendency for airway collapse. Lung hyperinflation, airflow limitation, and air trapping follow. Airspaces enlarge and may eventually develop blebs or bullae. (merckmanuals.com). It is a classification under COPD.
According to what the patient refers, symptoms and signs, the patient doesn’t suffer of any of this disease mentioned above. However, the patient has history of COPD, Heart Problems, he refers short of breath that is worse at night since 3 days ago, and he was the whole last night sitting on the chair, in the PE I found fine crackles in the lung bases, dullness to percussion to the bases, then, I made diagnosis for CHF decompensate, because due to the heart problems, dyspnea can occur during rest and at night, sometimes causing nocturnal cough. Dyspnea occurring immediately or soon after lying flat and relieved promptly by sitting up (orthopnea). (merckmanuals.com). Also I consider the patient has COPD decompensate, because the dyspnea that is progressive, persistent, exertional, or worse during respiratory infection appears when patients are in their late 50s or 60s. (merckmanuals.com).
Regarding the obesity diagnosis, the patient BMI is 45.52. According to BMI Chart for Men & Women (2016) a BMI of less than 18.5 classifies a person as underweight; between 18.5 and 24.9 as normal; between 25 and 29.9 as overweight; 30 and 39.9 as obese and over 40 as morbidly obese.
About treatment for Chronic systolic (congestive) heart failure (decompensate), I choose furosemide, because ia a loop diuretic, that clearly improve hemodynamics and symptoms inhibiting the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle. By effectively inhibiting sodium reabsorption, they also reduce water reabsorption. The loop diuretics bind to the luminal surface of the transporter; thus, they must be secreted into the tubular lumen. (Friedman, 2015). Then, with the furosemide use, the patient loses potassium, for this reason I added potassium to the treatment to replace what the patient will loses. A low potassium level can make muscles feel weak, cramp, twitch, or even become paralyzed, and abnormal heart rhythms may develop. (merckmanuals.com)
Antibiotic therapy has been shown to have a small but important effect on clinical recovery and outcome in patients with acute exacerbations of COPD. Therefore, antibiotic administration should be considered at the beginning of treatment for exacerbations of COPD. One of the first-line antibiotics in mild to moderate exacerbations is Azithromycin (Zithromax), 500 mg initially, then 250 mg daily. (aafp.org)
Treatment of obesity starts with comprehensive lifestyle management (diet, physical activity, behavior modification), which should include the following: self-monitoring of caloric intake and physical activity, goal setting, stimulus control, nonfood rewards, relapse prevention. (Hamdy, 2017)
The others conditions will continue with the same treatment.
Sethi, S., MD, (n.d.). Community-Acquired Pneumonia – Pulmonary Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-pneumonia
Harman, E. M., MD, (2016, August 11). Acute Respiratory Distress Syndrome Clinical Presentation: History, Physical Examination, Complications. Retrieved from http://emedicine.medscape.com/article/165139-clinical
Wise, R. A., MD, (n.d.). Chronic Obstructive Pulmonary Disease (COPD) – Pulmonary Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-pulmonary-disease-copd
Malcolm, J., MD, (n.d.). Heart Failure – Cardiovascular Disorders – Merck Manuals Professional Edition. Retrieved from http://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure
BMI Chart for Men & Women: Is BMI Misleading? – BuiltLean. (2016, November 13). Retrieved from http://www.builtlean.com/2013/07/17/bmi-chart/
Friedman, E. A., MD, (2015, April 1). Diuretics and Heart Failure: Background, Technical Considerations, Outcomes. Retrieved from http://emedicine.medscape.com/article/2145340-overview
Lewis, J. L., MD, (n.d.). Hypokalemia (Low Level of Potassium in the Blood) – Hormonal and Metabolic Disorders – Merck Manuals Consumer Version. Retrieved from https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/hypokalemia-low-level-of-potassium-in-the-blood
Hunter, M. H., MD, (n.d.). COPD: Management of Acute Exacerbations and Chronic Stable Disease – American Family Physician. Retrieved from http://www.aafp.org/afp/2001/0815/p603.html
Hamdy, O., MD, (2017, March 2). Obesity Treatment & Management: Approach Considerations, Patient Screening, Assessment, and Expectations, Weight-Loss Goals. Retrieved from http://emedicine.medscape.com/article/123702-treatment