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Evans Love

October 8, 2015
ITP Soap Note #2

SOAP Note
Overview:
Patient: Petra Wallace (65 y/o F)
Chief Complaint: Shortness of Breath
Temperature: 98
Blood Pressure: 85
Respiratory Rate: 18
Blood Pressure: 120/72

Subjective (Medical Interview)


HPI:
65 y/o female presents with progressive SOB x 2-3 days and productive cough x1 week.
Onset x2 weeks. Pt did not seem to be in acute respiratory distress during the visit, but
explained that she used to walk for an hour each and now can only walk 15 min before
needing rest (has a walker). Pt describes the quality as deep / frequent / keeps me up
at night / tight / muscle ache / not sharp. Pt reports pain was 3-4 /10 (initially) and 7 /
10 (currently). Does not radiate. Pt denies fever / chills / nausea / vomiting / night sweats /
sinus congestion / wheezing / sore throat / acid reflux / changes with temperature / changes
with animals / history of pneumonia / history of asthma.
Pt reports continuing hx of bronchitis over the past 6 months (4x in past 5 years / 15x in
lifetime). Pt was given a PROAIR inhaler in the past for urgent need and described proper
use but was not sure if the inhaler was still good, and she mentioned that she tried using her
nebulizer which helped with her bronchitis in the past (sx went away for 7-10 days) but that
it did not aid with current sx. Pt notes no aggravating factors or other alleviating methods
attempted. Pt reports sputum changed color in the last 2 days was clear, now green/yellow
and that it had a drop of blood. Pt states she lost 5 lbs over past few months. Pt mentioned
being nervous and concerned that the illness may be something that may put her in the
hospital (i.e. lung cancer). Pt claimed SOB was so bad today that she couldnt take her
granddaughter to school. Pt mentioned potentially getting CXR.
PMH:
Pt reports good general health. Pt reports no other serious illnesses or injuries in the past. Pt
reports 2 prior hospitalizations (2x vaginal births with no breastfeeding). Pt is not
menstruating (x10 years post-menopausal). Pt reports no recent travel history. Pt reports
allergies to sulfa drugs (rash) and seasonal allergies. Pt reports no other medications or nonpharmacologic treatments aside from trying the inhaler. Pt reports keeping up with annual
screenings. Pt reports visit to the ophthalmologist in may.
FHX:
Pt reports father had hx of emphysema (died @70), and that mother had hx of heart attack
@55 (died @ no year given). Pt reports no siblings, 2 healthy children, and 4 healthy
grandchildren. Pt reports no familial diseases of note.
SHX:

Pt is a retired real estate agent who is married with 2 children and 4 grandchildren. She lives
with her husband and has no pets. Normal day includes taking care of grandchildren (2 go to
school and two stay home). Pt noted diminished capacity recently due to shortness of
breath. Pt likes walking / hiking and states that it is easy to walk around Virginia Beach area
takes several trips a year to the Adirondacks. Pt reports she smokes 1x pack of
cigarettes /day since she was 20. Husband smokes the same amount. Father smoked as well.
Has not considered quitting. Pt reports no asbestos exposure (lives in a 14 years old
building) and no exposure to people sick with flu-like symptoms (got a flu shot).

Objective (Physical Examination)


Pleasant, older woman, who has complained of a cough and shortness of breath. BP=
120/72. HR 85 and regular. RR 18. T 98.
Skin
No suspicious nevi.
HEENT
Normocephalic, atraumatic. Hearing intact. Sinuses nontender. Pharynx without exudates.
Teeth and gums in good status. No uvular deviation.
Neck
Supple, without thyromegaly.
Lymph Nodes
No lymphadenopathy.
Lungs
Resonant. Diaphragms equal with 4cm movement. Full thoracic expansion. Resonant
percussion.
Cardiovascular
Rate and rhythm normal. JVP 6 cm above the right atrium; No carotid bruits. No JVD. Good
S1, S2. No murmurs heard today. No S3, S4. PMI 5th 1CS at mid clavicular line.
Abdomen
Active bowel sounds.
Soft, nontender, no hepatosplenomegaly.
Extremities
Without edema.

Objective (Labs)
Chest X-Ray with signs of COPD (Flattened Diaphragm / Hyperinflation).

Assessment
Differential Diagnosis
Acute Bronchitis
- Acute onset of symptoms
- Lack of physical findings to suggest other etiology (no fever, no egophony, not tactile
fremitus to suggest pneumonia)
COPD
- Smoking history
- Multiple similar episodes
Post Nasal Drip

- Has history of similar symptoms


Lung Cancer
- Often accompanied by weight loss (15 lbs or more) and hemoptysis
Problem List
1. Shortness of Breath
2. Coughing
3. Sleep Loss

Plan
Treatment
Nebulizer Treatment in Office
- Beta 2 agonist (albuterol), anticholinergic (ipratropium) or both bronchodilators
Inhaler for Home Use
- Albuterol (beta 2 agonist)
- Potential use of a spacer
Oral Steroids
- Short course for acute exacerbation
Antibiotics
- Not for bronchitis (usually viral) but used for suspected COPD exacerbation
Preventative Care
Smoking Cessation
- Counseling / information
Vaccination Plan
- Annual influenza vaccine
- Pneumococcal vaccine
Follow
-

Up
Dont go to the ED.
Follow up with us (in a week).
Spirometry test when she gets better.

Notes
Overview
Patient: Petra Wallace (65 y/o F)
Chief Complaint: Shortness of Breath
Temperature: 98
Blood Pressure: 85
Respiratory Rate: 18
Blood Pressure: 120/72

Subjective (Medical Interview)


Introduction (Hx)
1.
2.
3.
4.
5.

Student
Student
Student
Student
Student

introduces self
clarifies position or role
asks patient name
asks chief concern
clarifies patient agenda

History of Present Illness (Hx)


6. Chronology?
[ ] Onset?
[ ] Frequency?
[ ] Duration?
[ ] Progression?
Cough x 1 week.
Shortness of Breath x 2-3 days (Getting progressively
worse).
7. Location
[ ] Site
[ ] Radiation
Does not radiate.
8. Quality?
Deep / Frequent / Keeps me up at night / Tight /
Muscle Ache /
Not Sharp.
9. Severity?
[ ] Intensity/quantity
3-4
/10 (Initially)
7
/10 (Currently).
10. Context?

[ ] Setting
[ ] Precipitating events
Not asked.
11. Aggravating factor?
[ ] Aggravating factor(s)
None.
12. Alleviating factor?
[ ] Alleviating factor(s)
Tried:
- Nebulizer: which helped with her bronchitis (went away
for 7-10 days) but it is no longer working.
- PROAIR Inhaler: Given for urgent need but did not help
(patient described proper use but was not sure if the
inhaler was still good).
13. Associated symptoms?
Sputum (Had a drop of blood; Changed color in the last 2
days was clear, now green/yellow).
14. Patient's attributions or understanding of illness (FIFE)
[ ] Feelings
Nervous and concerned that the illness may be something
that may put her in the hospital.
[ ] Ideas
Lung Cancer.
[ ] Effect of function
Used to be able to walk for an hour (x 1 week) now only 15
min before needing rest (Has a walker). The Shortness of
Breath was so bad that she couldnt take her
granddaughter to school today.
[ ] Expectations
Find the problem, potentially get an X-Ray.
15. Continuing or active medical problems?
Continuing bronchitis over the past 6 months (4x in past 5
years / 15x in lifetime). Lost 5 lbs. over past few months.
Denies fever / chills / nausea / vomiting / night sweats /
sinus congestion / wheezing / sore throat / acid reflux /
changes with temperature / changes with animals / history
of pneumonia / history of asthma.
Past Medical History (Hx)

16. General state of past health?


Generally healthy.
17. Serious illnesses?
No other serious illnesses.
18. Serious injuries?
No other serious injuries.
19. Hospitalizations and or Surgeries?
2 prior hospitalizations (for the birth of her 2 children)
20. Menstrual/obstetrical Hx?
[ ] Menarche
[ ] Menses
[ ] Last menses
[ ] Childbirth Hx
[ ] Hx of breast feeding
Not menstruating (x10 years post-menopausal).
2 vaginal births with no breastfeeding.
[ ] N/A (male pt)
21. Exposures epidemiology?
[ ] Travel history
[ ] Overseas work
No recent travel history.
22. Allergies?
[ ] Medications
[ ] Foods
[ ] Environmental
[ ] Describe effect
[ ] Distinguish allergic response and drug effect
Sulfa drugs (rash) and seasonal allergies.
23. Current medications?
[ ] Prescription
[ ] Over-thecounter medicines
[ ] Vitamins
[ ] Supplements
None aside from trying the inhaler.
24. Non-pharmacologic treatments? IE. acupuncture, hypnosis,
yoga, meditation
None.

25. Age/sex appropriate screening tests? IE. Mammogram, pap, psa,


colonoscopy, etc.
Keeps up with screenings.
26. Other health providers seen? IE. Dentist, Ophthalmologist,
counselor, chiropractor, etc.
Ophthalmologist in May.
Family History (Hx)
27. Grandparents? (all)
[ ] Living or deceased
[ ] Age living or age at death
[ ] Health status/cause of death
Did not ask about Paternal or Maternal Grandmother /
Grandfather.
28. Parents? (both)
[ ] Living or deceased
[ ] Age living or age at death
[ ] Health status/cause of death
Father History of emphysema (Deceased @70).
Mother History of heart attack @55 (Deceased).
29. Siblings? (all)
[ ] Living or deceased
[ ] Age living or at death
[ ] Health status/or cause of death
None.
30. Children? (all)
[ ] No children
[ ] Living or deceased
[ ] Age living or age at death
[ ] Health status/cause of death
Children (2) Healthy.
Grandchildren (4) Healthy.
31. Hereditary/familial disease Hx?
[ ] HTN
[ ] Allergies
[ ] Heart disease
[ ] Cancer
[ ] Diabetes
[ ] Obesity
[ ] Alcoholism

[ ] Mental health problems


None. (Included asthma and cystic fibrosis)
32. Family dysfunction Hx?
[ ] Domestic abuse
[ ] Recreational drug use
Not asked.

Social History (Hx)


33. Demographic data?
[ ] Age
[ ] Marital status
[ ] Education
[ ] Ethnicity
65 years old, married.
34. Occupation?
Occupation
[ ] Environmental hazards at work?
[ ] Toxic hazards at work?
[ ] Other
Retired (Used to be a real estate agent).
35. Functional status?
[ ] Exercise
[ ] Activities of Daily Living if indicated
[ ] Independent ADLs if indicated
[ ] Sleep patterns
[ ] Recreation/ relaxation
[ ] Other
Normal day includes taking care of grandchildren (two go
to school and two stay home). Diminished capacity
recently due to shortness of breath.
Likes walking / hiking and states that it is easy to walk
around Virginia Beach area. Takes several trips a year to
the Adirondacks.
36. Nutrition?
[ ] Describe what you usually eat in a day
[ ] Describe what you usually drink in a day
[ ] Supplements
[ ] Restrictions
[ ] Other
Not asked.

37. Relationships?
[ ] W/marital or significant other
[ ] W/family
[ ] W/household composition
[ ] W/work composition
[ ] Other
Lives with her husband (grandchildren do not live at
home). No pets.
38. Support?
[ ] Stressors
[ ] Support sources
[ ] Coping styles
[ ] Other
Husband.
39. Cultural/ religious factors that influence type of care? Any faith
or cultural beliefs to consider with patient health care.
Not asked.
40. Tobacco?
[ ] Type?
[ ] How often?
[ ] How much?
[ ] How long?
[ ] Attempted to quit?
[ ] Passive smoking?
Smoked 1x pack of cigarettes per day since she was 20.
Husband smokes the same amount. Smokes outside. Has
not considered quitting. Father smoked as well.
41. Alcohol use?
[ ] Type?
[ ] How much?
[ ] How long?
[ ] How often?
[ ] Drink and drive?
Not asked.
42. Alcoholism screening (CAGE)
[ ] Tried to cut down
[ ] Annoyed by criticism
[ ] Ever felt guilty
[ ] Morning eye opener
[ ] Other screening for dependency

Not asked.
43. Recreational drug use?
[ ] Type?
[ ] How much?
[ ] How often?
[ ] How long?
[ ] Other Screening for dependency
Not asked.
44. Sexual functioning
[ ] Satisfaction
[ ] Safer sex practices
[ ] Contraception
[ ] Other
Not asked.
45. Sexual history
[ ] Orientation/ partner preference
[ ] Coitarche (age first active)
[ ] Partner risk
[ ] Number of partners in last 6 months
[ ] Number of lifetime partners
[ ] STDs?
Not asked.
46. Physical violence?
[ ] Do you feel safe in your relationship s?
[ ] Are you concerned about you or your children's safety at your
home/neighborhood/work?
[ ] Ever been hurt or abused by someone close to you?
[ ] Other
Not asked.
47. Infectious or toxic exposure Hx? Patient exposure to infections
or toxins from family members, work, environment, etc.
[ ] Infection (ie: TB)
[ ] Chronic (ie: HIV/AIDS)
[ ] Toxins (ie: asbestos, lead)
[ ] Seasonal (ie: influenza)
[ ] Other
No asbestos exposure (lives in a 14 years old building).
No exposure to people sick with flu-like symptoms (got a
flu shot).
48. Injury risk prevention

[
[
[
[
[
[

]
]
]
]
]
]

Smoke alarm
Sun protection
Helmets
Automotive safety
Firearm safety
Other
Not asked.

Closure (Hx)
49. Closure
[ ] Assure patient understanding
[ ] Next communication between Pt. and care giver
[ ] Closing salutation
[ ] No closure