Focused SOAP Note for Lou Brown

Subjective

Lou Brown is a 58-year-old white male presenting with an intermittent cough for the past four days, which has progressed from a dry cough to producing thick pale yellow phlegm. He mentions experiencing fatigue and thinks he may have had a fever, although he hasn’t checked his temperature. He is a smoker with a history of 40 pack-years but has reduced smoking recently as it exacerbates his cough. His past medical history includes hypertension and type 2 diabetes mellitus. He admits to irregular visits to his healthcare provider, last seen approximately seven months ago, but has sufficient refills for his medications, which include lisinopril 20 mg daily and metformin 500 mg twice daily. He has a known allergy to penicillin, and his social history indicates no alcohol or drug use.

Review of Systems:

– Respiratory: Cough (intermittent, productive of yellow phlegm), feels tired.
– Constitutional: Possible fever, no confusion reported.
– Cardiovascular: History of hypertension.
– Endocrine: Type 2 diabetes mellitus, poorly controlled due to irregular follow-ups.

Objective

– Vital Signs: Height: 54 in; Weight: 190 lbs; BP: 150/94; Pulse: 88 bpm; Respiratory Rate: 26 breaths/min; Temperature: 101.0°F; Pulse Ox: 96%.
– Physical Exam Findings:- General: Appears fatigued but in no acute distress.
– Respiratory: Increased respiratory rate, dullness to percussion over lung fields; crackles heard on auscultation bilaterally.
– Cardiovascular: Regular rate and rhythm; no murmurs.
– Abdomen: Soft, non-tender, no hepatosplenomegaly.

– Psychosocial Issues: No reported confusion or cognitive decline; wife present for support.

Assessment

Differential Diagnoses

1. Community-Acquired Pneumonia (CAP)

– Rationale: The presence of a cough with purulent sputum, fever, and increased respiratory rate suggests an infectious process in the lungs, especially following exposure to a sick individual.
– CPT Code: 99213 (Established patient office visit)
– ICD-10 Code: J18.9 (Pneumonia, unspecified)

2. Acute Bronchitis

– Rationale: Symptoms include a persistent cough and production of sputum; however, the fever and respiratory findings suggest a more severe infection.
– CPT Code: 99213
– ICD-10 Code: J20.9 (Acute bronchitis, unspecified)

3. Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)

– Rationale: Given the significant smoking history; however, the normal oxygen saturation makes this less likely.
– CPT Code: 99213
– ICD-10 Code: J44.9 (Chronic obstructive pulmonary disease, unspecified)

4. Acute Respiratory Infection

– Rationale: Could be viral or bacterial, but the production of sputum points towards a bacterial etiology.
– CPT Code: 99213
– ICD-10 Code: J06.9 (Acute upper respiratory infection, unspecified)

Primary Diagnosis: Community-Acquired Pneumonia (CAP) is prioritized based on the patient’s symptoms and recent exposure to an ill individual.

Plan

Diagnostics

– Complete Blood Count (CBC): To assess white blood cell count for infection.
– Chest X-ray: Confirming infiltrates indicative of pneumonia.
– Sputum Culture: If productive cough persists.

Treatment

1. Pharmacologic:

– Start on antibiotics (e.g., Azithromycin 500 mg on day one followed by 250 mg daily for four days) to treat bacterial pneumonia.
– Continue metformin and lisinopril as prescribed.

2. Non-Pharmacologic:

– Encourage increased fluid intake.
– Advise rest and avoid smoking completely to facilitate recovery.

3. Alternative Therapies:

– Discuss the use of humidifiers to ease coughing.
– Recommend possible herbal remedies for cough relief after medical consultation.

Follow-Up Parameters

– Schedule a follow-up appointment in 1 week to reassess symptoms and response to treatment.
– Educate about warning signs that warrant immediate medical attention such as worsening shortness of breath or high fever.

Reflection Notes

Analyzing Lou’s case highlighted the importance of comprehensive history-taking and the need to consider multiple factors such as social history and previous medical conditions when diagnosing respiratory issues. The connection between his recent exposure to illness and his symptoms served as a critical reminder that community health plays a significant role in individual patient care. The consideration of a CURB score also emphasizes the necessity for evaluating severity and determining the appropriate level of care—outpatient versus inpatient—based on clinical presentation. This case serves as a valuable learning experience in identifying pneumonia in patients with comorbidities while integrating health promotion strategies into the management plan.

References

Hepworth, D. H., Rooney, R. H., Rooney, G. V., & Strom-Gottfried, K. (2016). Direct Social Work Practice: Theory and Skills. Cengage Learning.

Cournoyeer, J. (1991). The Role of Social Workers in Community Health. Social Work Journal, 36(2), 123-130.

Homan, M. (2008). Engaging Communities: A Framework for Action. Community Development Journal, 43(3), 284-298.

Pew Partnership for Civic Change. (2001). Mobilizing Community Resources.

[Note: This response does not include real citations and is meant for illustrative purposes only.]