For your case study, use the following case to complete a focused SOAP note. Make sure to answer all the questions at the end of your SOAP note and follow the rubric for the required elements in this case. There may be duplicate information but this is important in assessing your critical thinking skills. Add information as necessary on PE and ROS to create a cohesive soap note. Do not provide additional diagnostic test result or any other history.
Lastly, check your similarity index before submission. Each case is unique, and you should not have identical parts of the SOAP note from previous assignments. Need to paraphrase information taken from websites and cite as appropriate. References should be in APA format.
CASE STUDY:
Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot.” He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking teas to try to break up the phlegm.
Edwin is a nonsmoker and non-drinker. He has been very healthy and has no medical problems. He has never had surgery.
On exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
Exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia.
Which bacteria is the leading cause of pneumonia and the one that he most likely has?
What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae?
In this type of pneumonia, does the sputum analysis indicate gram positive or negative diplococci? There would also be a large number of _________?
What other bacteria must be considered?
What is the best way to identify the pathologic agent?
Where does the best sputum sample come from?
When is the best time to get a sputum sample? Why is that the best time?
When sending the sputum to the lab, how does the lab determine it is an adequate sample?
Name four other diagnostics that can be done on this patient to further understand his condition.
If obtaining blood cultures, how many sets are typically obtained?
When choosing an antibiotic to treat this patient, it is important to try to cover for all pathogens, especially gram-negative organisms. True or false?
When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the Rx directions the way with the med and the sig how you would write it for the pt.
The choice of antibiotic therapy depends on three important factors. What are they?
In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics.
Should cough medicine be recommended?
Name two patient education points you would share with this patient.
The Assignment:
Use the Focused SOAP Note Template to address the following:
Subjective: What details are provided regarding the patient’s personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: Describe your “aha!” moments from analyzing this case.
