For Your Case Study Use The Following Case To Complete

For Your Case Study Use The Following Case To Complete a Focused Soap

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. Add information as necessary to create a cohesive soap note.

Case Study: Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past two days, he has started coughing up thick pale-yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse. He has also felt very tired. He has taken Tylenol off and on and it does help slightly.

About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.

PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.

Medications: lisinopril 20 mg daily; metformin 500 mg twice daily

Allergies: Penicillin

Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.

Vitals: Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral; Pulse oximetry 96%

The questions below need to be answered at the end of the SOAP note:

1. Document the history questions you would ask the patient.

2. What questions would you ask related to the current complaint?

3. What questions would you ask related to his comorbidities?

4. What physical assessment would you obtain? Describe what you would be looking for.

5. What labs/diagnostics would you order? List your top four differential diagnoses. Explain your rationale for your top diagnosis.

6. What is a CURB Score?

7. When his labs come back, his CMP shows that his BUN is 21. Based on that information and his presentation, what is his CURB score and how did you arrive at that score? Based on his CURB score, should he be treated on an outpatient or inpatient basis? His chest x-ray does indeed show infiltrates. What would be your treatment plan for him?

8. Name 3 health promotion topics that you should discuss with him. What would your follow-up plan be?

Paper For Above instruction

Lou Brown, a 58-year-old male with a history of hypertension and type 2 diabetes mellitus, presents with a four-day history of intermittent cough, recently productive with thick, pale-yellow sputum. His presentation suggests a lower respiratory tract infection, likely pneumonia, compounded by his comorbid conditions and lifestyle habits. This paper discusses the comprehensive assessment, differential diagnosis, risk stratification, and management plan for Lou, emphasizing clinical reasoning supported by current guidelines.

Patient History and Questions

A thorough history is critical to forming an accurate diagnosis and management plan. Regarding Lou’s current complaints, I would inquire about the onset, duration, and progression of his cough and sputum production, including any associated symptoms like chest pain, shortness of breath, hemoptysis, or wheezing. Questions about fever, chills, night sweats, weight loss, or fatigue would help assess severity. Given his recent exposure—playing poker with a sick individual—questions about recent illnesses, contact with others with respiratory symptoms, or recent travel are pertinent.

For his comorbidities, I would ask about his blood pressure control, recent blood glucose levels, medication adherence, and any complications like neuropathy or retinopathy. Questions about medication side effects, changes in appetite, or other symptoms related to diabetes or hypertension are important. His smoking history warrants discussion about current smoking status, duration, smoking cessation attempts, and exposure to secondhand smoke. Lifestyle factors such as alcohol use or drug use should also be explored to assess overall health risks.

Physical Assessment

The physical exam would focus on respiratory and cardiovascular systems. Inspection would include observing breathing effort, use of accessory muscles, and any cyanosis. Palpation and percussion could identify areas of dullness indicating consolidation. Auscultation would evaluate breath sounds for crackles, egophony, or bronchial breath sounds suggestive of pneumonia. Vital signs include temperature, blood pressure, pulse, respiratory rate, and oxygen saturation. A thorough exam would also include examination of the neck (for lymphadenopathy), neck structure, and rest of the physical assessment to rule out other possible causes.

Laboratory and Diagnostic Tests

Laboratory tests include a complete blood count (CBC) to assess leukocytosis indicating infection, and C-reactive protein (CRP) or procalcitonin to gauge severity. A comprehensive metabolic panel (CMP) evaluates organ function, with specific attention to BUN and renal function. Sputum culture and Gram stain would help identify the pathogen, especially with purulent sputum. Chest X-ray remains the gold standard in pneumonia diagnosis, revealing infiltrates, consolidation, or other pathology. A pulse oximetry or arterial blood gas could assess oxygenation status.

Top differential diagnoses include:

1. Community-acquired pneumonia (most probable based on presentation and radiology).

2. Acute bronchitis.

3. Chronic obstructive pulmonary disease (exacerbation).

4. Heart failure exacerbation.

The most likely diagnosis is community-acquired pneumonia, supported by the productive cough, fever, tachypnea, elevated temperature, and infiltrates on chest x-ray.

CURB-65 Score and Its Application

The CURB-65 score stratifies pneumonia severity to guide treatment decisions, considering Confusion, Urea (BUN), Respiratory rate, Blood pressure, and age ≥65 years. Each parameter scores 1 point.

Lou’s BUN is 21 mg/dL, slightly elevated. His age is 58 (

- Confusion: No (0)

- Urea: 21 mg/dL (1 point)

- Respiratory rate ≥25: Yes (1 point)

- Blood pressure systolic ≥90 and

- Age ≥65: No (0 points)

Total score: 2. This suggests moderate pneumonia severity, warranting hospitalization for close monitoring, oxygen therapy, and intravenous antibiotics.

Treatment Plan

Given his CURB-65 score of 2 and infiltrates on CXR, Lou would benefit from inpatient management. Initial therapy includes empiric antibiotics targeting common pathogens like Streptococcus pneumoniae, considering his outpatient status and possible resistant organisms. Antibiotics such as ceftriaxone plus azithromycin are appropriate. Supportive care involves oxygen supplementation to maintain saturation above 92%, antipyretics, and hydration. Management of comorbidities, including optimizing hypertension and diabetes control, is essential to improve outcomes. Monitoring of respiratory status and response to therapy is critical.

Health Promotion and Follow-Up

Health promotion topics include smoking cessation counseling to reduce the risk of recurrent respiratory infections and progression of COPD if applicable. Additionally, vaccination against pneumococcus and influenza should be discussed to prevent future illnesses. Emphasizing the importance of medication adherence, regular follow-up with primary care, and blood pressure and glucose control are vital in managing his chronic conditions. Education on recognizing early signs of worsening respiratory symptoms facilitates prompt intervention.

Follow-up includes re-evaluation in 48-72 hours to monitor clinical progress, repeat chest x-ray if symptoms persist or worsen, and coordination with his primary care provider for ongoing management of hypertension and diabetes. Ensuring vaccination status and ongoing health maintenance is also part of comprehensive care.

References

• Mandell, L. A., et al. (2019). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 68(2), e1–e72.
• Lim, W. S., et al. (2019). BTS guideline for management of community pneumonia. Thorax, 74(Suppl 3), iii1–iii55.
• American Lung Association. (2022). COPD and Respiratory Infections. Retrieved from https://www.lung.org
• Subramaniam, K., et al. (2022). Clinical assessment of pneumonia severity in adults. American Journal of Medicine, 135(7), 875-880.
• patients' management. Journal of Respiratory Medicine, 15(4), 231-239.
• National Heart, Lung, and Blood Institute. (2021). Guideline on the management of hypertension. NHLBI Publications.
• American Diabetes Association. (2022). Standards of Medical Care in Diabetes—2022. Diabetes Care, 45(Supplement 1), S1–S264.
• Infection Control Guidelines. (2021). CDC Recommendations for Pneumococcal Vaccination. Morbidity & Mortality Weekly Report, 70(3), 75–78.
• Jones, R. N., et al. (2019). Antibiotic resistance in Streptococcus pneumoniae. Journal of Infectious Diseases, 220(11), 1729–1737.
• Gordon, C., et al. (2020). Smoking cessation and respiratory health. Respiratory Medicine, 165, 105928.