NR 601 Week 1 SOAP Note -LJ Case Study

NR 601 Week 1 SOAP Note -LJ Case Study

NR 601 Week 1 SOAP Note -LJ Case Study

LJ, 65 yr Hispanic male

Subjective

CC: increased Shortness of breath

O: few months ago.

L: thoracic region

D: several months

C:  Increased SOB with chronic cough, sometimes production of whitish sputum

A, R, and T: unknown

PMH:

Hx of HTN, cataracts, and oseteoarthritis

Surgery: left knee arthroplasty in 2013

NKDA

Current medications:

Ibuprofen 600 mg po TID

Lisinopril 20 po QD

Hydrochlorothiazide 25 mg po QD

Simvastatin 20 mg QD

Meloxicam 7.5 mg QD

Social History

65 pack year history of cigarette smoking; denies alcohol intake or illicit drug use; is married and recently retired.

Family History

Mom- “mild” stroke

Dad- HTN

Brother – hyperlipidemia

ROS

Constitutional: denies fever or chills

Cardiopulmonary:  (+) productive cough, (+) white sputum,   (+) SOB

GI: unknown

 

Objective

Vital signs: BP 138/88; HR 88 (regular), RR 18, T 98.8 height 5’7”, weight 175 pounds, BMI 27.41

General appearance: Thin and mildly dyspneic

Lungs: Mild end-expiratory wheezing. Pursed-lip breathing noted and has a prolonged expiratory phase. Chest x-ray shows pulmonary hyperinflation, flattening of the diaphragm; Pulmonary function test (after bronchodilation with 2 puffs albuterol—FEV1/FVC ratio 0.60 FEV1 60% of predicted value)

Heart: S1 and S2 RRR with distant heart tones. No murmurs

Abdomen: Soft, non-tender with positive bowel sounds. No abdominal bruits

Extremities: Full ROM of all extremities. No edema. All pulses 2+

 

Assessment

Primary Diagnosis

1. Emphysema (J43.9) – Goroll and Mulley (2014) explained that emphysema is caused from alveolar destruction and leads to difficulty breathing, especially on exertion, occasional cough and minimal sputum production. The US National Library of Medicine (2017) reports that individuals feel it is difficult to catch one’s breath and may actually a chronic cough.   Emphysema may also continue to worsen without proper treatment.  Once treated, the individual can experience exacerbations of the disease.   This disease is considered just one condition under the umbrella term Chronic Obstructive Pulmonary Disease (COPD).  This patient is having shortness of breath that is worse when performing ADLs, has a cough, with the occasional white sputum.

Secondary Diagnoses:

1. Nicotine Dependence (F17.200): Nicotine dependence can cause individuals to go through withdrawal when they do not have a cigarette.  Symptoms include irritability, anxiety, craving tobacco products and feeling hungry (CDC, 2017). Nicotene dependence is defined as an addiction, which means you still use the substance despite knowing it is causing you harm.  Those addicted to smoking, smoke daily, tend to have a cough and feel short of breath just as this patient does.
2. Hypertension (R03.0) – HTN is defined as multiple elevated BP readings greater than 140 mmHg, while sever HTN is a systolic greater than 180 mmHG or diastolic greater than 110 mmHg. Symptoms include headache, feeling flush, anxious, or feeling uneasy (Gauer, 2017). Patients diagnosed with high blood pressure must take their medication daily and not skip any doses.  While taking medication this patient’s blood pressure is 138/88.
3. Hyperlipidemia (E78.5)- Hyperlipidemia is one of the most common causes for ACS, and is defined by elevated levels of LDL, triglycerides, and total cholesterol (Last, Ference, & Falleroni, 2011).
4. Osteoarthritis (M19.0) – Osteoarthritis is also known as Degenerative Joint Disease and is a condition in which wear and tear takes place on joints, usually unilaterally. This is caused by being obese or performing certain jobs over the years (Brauer, 2012).
5. Overweight (E66.3) – Overweight is defined by having a BMI between 25 and 29.9. BMI does not measure fat but is a good indication of future health outcomes (CDC, 2017).

Differential Diagnosis

1. Non-Small Cell Lung Cancer (C34.90) – This type of cancer is the most common type of lung cancer and is mostly caused by smoking. US National Library of Medicine (2015) describes this type of cancer as one that spreads slowly and can present with symptoms of persistent chronic cough, fatigue, shortness of breath, chest pain, and wheezing.  This patient has a chronic cough and shortness of breath and is at high risk due to the fact that he’s a smoker.

Plan of Care

Diagnostics:

Arterial blood gas.  An ABG can assess the patient’s arterial oxyhemoglobin saturation and desaturation and can pose as a useful tool moving forward with the treatment plan (Gorroll & Mulley, 2014).

Repeat FEV in 3 months.

Colonoscopy if patient has not had one. It is recommended that colonoscopies be performed on any adult over the age of 50 (CDC, 2016).

Spirometry is the gold standard test related to the limitation of fixed airflow (Overington et al, 2014).

Routine bloodwork – CBC, CMP, Lipid profile, ferratin

Medications:

New-

…

Patient Education:

Nicotine Dependence-

• Quit smoking immediately. Smoking cessation programs are available for free through health insurance.
• Smoking is the leading modifiable risk factor in many life-threatening diseases (CDC, 2016).

COPD –

• Take medications as directed.
• It is important to stay active and slowly increase distance walked (US National Library of Medicine, 2017).
• Do breathing exercises.
• Eat 5-6 smaller meals every day and try to avoid increased fluid intake before meals. This will help decrease difficulty breathing.
• Call your provider if you begin feeling anxious or depressed
• Try to save energy while performing tasks by spacing them out and sitting down while performing them if able to (US National Library of Medicine, 2017).
• Call provider immediately if you have a fever, have blue fingertips or extremities, have frequent headaches, notice yourself increasing the workload of your breathing or feel the need to lean forward when taking a breath (US National Library of Medicine, 2017).
• Call 9-1-1 if you are experiencing chest pain or extreme shortness of breath (US National Library of Medicine, 2017).

Hypertension –

• Continue taking medications as directed.
• Try to keep a journal of blood pressures in the morning. Use a portable wrist BP machine.
• Avoid foods high in sodium or cholesterol (Gauer, 2017).

Overweight –

• Begin an exercise regimen once you feel you are able to increase your activity level walking 30 minutes three times per week.
• maintain a healthy diet.  Apps like myfitnesspal can help you keep on track.

Health Promotion-  It is important to get flu shot every year.  Anyone over 65 should also receive the pneumococcal vaccine (CDC, 2017).

Referrals/Consults: Patient should follow up with pulmonologist within one week (Gorroll & Mulley, 2014).

Follow-up: Patient should return to office in 6 weeks to evaluate if medication regimen is working and evaluate patient’s plan to quit smoking.

 

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References

Brauer, S. (2012). Osteoarthritis. Journal of Physiology, 58(2); 133.

Centers for Disease Control and Prevention. (2017). Colorectal cancer screening tests. Retrieved from https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm

Centers for Disease Control and Prevention. (2017). Defining adult overweight and obesity. Retrieved from https://www.cdc.gov/obesity/adult/defining.html (Links to an external site.)Links to an external site.

Elsawy, B., & Higgins, K.E. (2011). The geriatric assessment. American Family Physician, 83(1): 48-56.

Gauer, R. (2017). Severe Asymptomatic Hypertension: Evaluation and Treatment. American Family Physician, 95(8), 492-500.

Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer.

Haroon, S., Jordan, R., Takwoingi, Y., & Adab, P. (2015). Diagnostic accuracy of screening tests for COPD: a systemic review and meta-analysis. BMJ Open; 5(10), e008133.

Kinkade, S., & Long, N. A. (2016). Acute bronchitis. American Family Physician, 94(7), 560-565.

Last, A.R., Ference, J.D., & Falleroni, J. (2011). Pharmacologic treatment of hyperlipidemia. American Family Physician, 84(5): 551-558.

Overington, J. D., Huang, Y. C., Abramson, M. J., Brown, J. L., Goddard, J. R., Bowman, R. V., … Yang, I. A. (2014). Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions. Journal of Thoracic Disease, 6(11), 1586–1596. http://doi.org/10.3978/j.issn.2072-1439.2014.11.25

US National Library of Medicine. (2017). Emphysema.  Retrieved from  https://medlineplus.gov/emphysema.html (Links to an external site.)Links to an external site.

US National Library of Medicine. (2015). Lung cancer – non-small cell.  Retrieved from  https://medlineplus.gov/ency/article/007194.htm