| Name: PC | Time: 1600hrs | |
| Date: 6/7/2017 | Age: 58 years old | Sex: Male |
| SUBJECTIVE | ||
| CC: “I am coughing, my chest is painful, and I am losing my breath.” | ||
| HPI: PC was well until one month ago when he developed a common cold due to Hemophilus influenza. He went to the hospital, and the physician prescribed cough medications that he does not remember. He experienced improvement one day after taking the drugs and stopped using them. His wife had never been smoking in the house due to her husband’s allergy to smoke. However, she started smoking two weeks ago when PC said he was not allergic to smoke anymore. Since then, PC has developed dyspnea, increased mucus production, and chest discomfort. Two days ago, he started producing yellowing-gray sputum. He is worried that he might be unable to breathe, and he needs treatment.
PC provided the HPI as follows: O- Two weeks ago. L- Feels pain in the chest. D- Intermittent. C- Dull. A- Symptoms are worse in cold weather. R- No relief. T- Symptoms worsen at night. T- No drugs. S- Symptoms rated at 3/10. |
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| Medications: Not on drugs. | ||
| PMH
Allergies: Allergic to smoke. Drug Intolerances: None notified. Traumas or Chronic Illness: Not having any of them. Surgeries and Hospitalizations: Never undergone any of them. |
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| Family History: PC’s family has no history of chronic diseases. Both parents live in the nursing home. He has two brothers who are both healthy. | ||
| Social History: PC is married. His wife smokes but never takes alcohol. PC consumes alcohol but never smokes. They live with their two children. PC is a college graduate, and he works as a sales person. | ||
| ROS | ||
| General: Denies any current experiences of weight loss and fatigue. No chills. | Cardiovascular: Positive for chest pain but denies claudication or orthopnea. No edema of extremities. | |
| Skin: Denies easy bruising, bleeding, or any skin lesions. | Respiratory: Positive for dyspnea on exertion, rhinitis, and production of yellowish-gray sputum. Furthermore, positive for chest discomfort. | |
| Eyes: Does not use visual aid and denies any visual problems. | Gastrointestinal: Positive for the loss of appetite but denies vomiting, nausea, or hemorrhoids. | |
| Ears: Denies discharges from the ears, tinnitus, or any experiences of hearing loss. | Genitourinary: Denies having masses or lesions on the penile shaft. Denies history of STDs. | |
| Nose, Mouth, and Throat: Denies sinus problems, oral sores, or a sore throat. | Musculoskeletal: Positive for the fatigue but denies muscle cramps. | |
| Breast: Denies pain or breast masses. | Neurological: Denies paresthesia, seizures, or vision problems. | |
| Heme/Lymph/Endo: Denies polyuria or polydipsia. Last HIV test was three years ago, and it was negative. | Psychiatric: Denies depression or suicidal thoughts. | |
| OBJECTIVE | ||
| BP: 117/78mmHg | Temp: 100 F | |
| Weight: 124lbs
Height: 5’ 6.” BMI: 20 kg/m2 |
Pulse: 82bpm | Resp: 19 bpm |
| General Appearance: An elderly male with cyanosis who appears sick but in no acute distress. | ||
| Skin: Skin is cyanosed. | ||
| HEENT:
Head: Normocephalic. No lesions, deformities, or hair on the head. Eyes: Intact visual acuity and no discharges. Ears: Atraumatic auditory meatus with clear landmarks on the outer ear. Nose: Edema noticed with an excess amount of mucus from the nostrils. Neck: Limited ROM as he complains of a headache that occurs at night. Mouth and Throat: 32 teeth and no lesions or exudates. |
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| Cardiovascular: Auscultation reveals regular heartbeat with no murmurs or palpitations. Capillary refill takes two seconds in spite of the slight cyanosis. | ||
| Respiratory: Coughs and holds the chest. No rhonchi but wheezes noticed. No crackles. Breathing is fast and shallow. | ||
| Gastrointestinal: No abdomen obesity but active BS noted. | ||
| Breast: No masses identified. | ||
| Genitourinary: No masses or lesions on the genitals. | ||
| Musculoskeletal: No swelling of all extremities. Limited ROM of the upper limbs. Full ROM of the lower limbs. | ||
| Neurological: Clear speech that is interrupted by a cough. Upward gait noted. | ||
| Psychiatric: Maintains the eye contact and responds to the questions as asked. Oriented and kempt. | ||
| Lab Tests: Sputum test has been done. No infection has been detected. | ||
| Special Tests: Chest X-ray results are available. Pneumonia has been ruled out. | ||
| Diagnosis | ||
| Differential Diagnoses
· 1- Asthma: (Z77.22). The subjective data reveals that PC’s wife has been smoking in the house for the past two weeks. The objective data shows that he has had shortness of breath and excessive mucus production. Santos (2016) argues that smoke can exacerbate asthma and lead to excessive mucus production and dyspnea. · 2- Bronchiolitis: (J21.9). This diagnosis is suspected because it also results in coughing and excessive mucus production (Meissner, 2016). · 3- Chronic Obstructive Pulmonary Disease: (J44.0). PC can have COPD due to sputum production and dyspnea. Final Diagnosis Acute Bronchitis. (J20.1). PC has been coughing for the past two weeks. He confirms that he had a common cold one month ago. However, he continued experiencing chest discomfort and failed to adhere to medications as prescribed. His wife started smoking in the house two weeks ago, which predisposed him to bronchitis (Hart, 2014). Currently, the objective data reveals that PC is coughing; he produces yellowing-gray mucus and has a slight fever. According to Hart (2014), acute bronchitis can result from influenza infection, and the patient may present with coughing, fever, and chest discomfort. The symptoms are present in this case, and the ICD-10 Code of J20.1 identifies acute bronchitis that occurred due to Hemophilus influenza. |
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| Plan Including Education
Further Testing: ABG has been done. SPO2 is 96%. Pharmacologic Management: PC does not have a bacterial infection. Therefore, antibiotics have been neglected. PC has been given ten tablets of tramadol in the strengths of 50mg to alleviate chest pain. He will take half a tablet by mouth daily until the fourth day during the follow-up. Moreover, PC has been given albuterol inhaler. He should inhale four times a day for four days. Finally, he will drink Boericke & Tafel Cough & Bronchial Syrup before going to bed, which will minimize coughing. According to Hart (2014), this regimen is appropriate for the management of acute bronchitis. Non-Pharmacologic Management: Pulmonary rehabilitation has been done, and PC has improved his rate of breathing. Education: PC neglected to complete the previous dosage for influenza. Thus, he has been told to comply with the current medication regimen. He has also been told to tell his wife to stop smoking in the house to avoid exacerbation of the symptoms during treatment. Follow-Up: PC will come back after four days for the assessment of his symptoms and determination of further diagnosis and treatment. Evaluation of Patient Encounter: PC cooperated well during history taking and confirmed that he was under treatment of influenza one month ago. The persistence of chest discomfort, coughing, and exposure to smoke every night assisted in arriving at a definite diagnosis of acute bronchitis (Hart, 2014). The management ruled out infections and followed the evidence-based guidelines in recommending tramadol, albuterol, and cough syrup. The management also considers a follow-up to assess his recovery. The patient has been told to comply with the drugs until the fourth day when he will come for the check-up because he has a history of defaulting. Therefore, PC is undergoing adequate management, and his adherence to medications will guarantee a quick recovery from acute bronchitis. |
| SOAP Note on Bacterial Conjunctivitis |