Professional Documents
Culture Documents
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
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 (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
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
Student
Student
Student
Student
Student
introduces self
clarifies position or role
asks patient name
asks chief concern
clarifies patient agenda
[ ] 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)
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