Soap Note 1 Acute Conditions Due By 02062021 At 1159 Pm ✓ Solved

Soap Note 1 Acute Conditions Due By 02062021 At 1159 Pm

Pick any Acute Disease from Weeks 1-5 (ACUTE BRONCHITIS). Must use the sample template for your soap note, keeping this template for when you start clinicals. Use APA format and must include a minimum of 2 Scholarly Citations. SOAP notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program). Turn it in Score must be less than 25% or will not be accepted for credit; it must be your own work and in your own words. The Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

Paper For Above Instructions

Soap Note for Acute Bronchitis

Patient Information

Name: John Doe

Age: 35

Gender at Birth: Male

Gender Identity: Male

Source: Self-reported

Allergies: None

Current Medications: None

PMH: No significant past medical history

Immunizations: Up to date

Preventive Care: Regular checkups

Surgical History: None

Family History: No significant family history of respiratory diseases

Social History: Non-smoker, occasional alcohol use

Sexual Orientation: Heterosexual

Nutrition History: Balanced diet

Subjective Data

Chief Complaint: The patient states, "I have been experiencing a persistent cough for the past week, and I feel short of breath."

Symptom analysis/HPI: Pt reports that the cough began about a week ago, worsening over the last few days. The cough is described as dry but is sometimes productive with clear sputum. Pt denies fever but reports feeling slightly fatigued. The shortness of breath is noted during physical activities and is not associated with chest pain.

Review of Systems (ROS):

  • Constitutional: Pt denies fever or chills.
  • Neurologic: Pt denies headaches or dizziness.
  • HEENT: Pt reports a scratchy throat.
  • Respiratory: Pt states shortness of breath with exertion.
  • Cardiovascular: Pt denies palpitations.
  • Gastrointestinal: Pt denies nausea or vomiting.
  • Genitourinary: Pt denies any urinary issues.
  • Muskuloskeletal: Pt denies joint pain.
  • Skin: Pt denies rashes or lesions.

Objective Data

Vital Signs: BP: 120/80 mmHg, HR: 78 bpm, RR: 18/min, Temp: 98.6°F

General Appearance: The patient appears slightly fatigued but in no acute distress.

Neurologic: Alert and oriented to person, place, and time.

HEENT: Mild erythema in the throat, no nasal discharge.

Cardiovascular: Regular rate and rhythm, no murmurs or gallops.

Respiratory: Diminished breath sounds bilaterally, wheezes noted on expiration.

Gastrointestinal: Soft and non-tender, bowel sounds present.

Muskuloskeletal: Full range of motion in all extremities.

Integumentary: Skin warm and dry.

Assessment:

Subjectively, the patient reported worsening cough and shortness of breath over the past week with no associated fever. Objectively, vital signs are within normal limits, but respiratory examination reveals wheezing. These findings are consistent with an acute bronchitis diagnosis (ICD10 J20.9).

Differential Diagnosis:

  • 1. Acute bronchitis
  • 2. Viral upper respiratory infection
  • 3. Pneumonia

Plan:

Labs and Diagnostic Tests to be Ordered:

  • Chest X-ray to rule out pneumonia.
  • Complete blood count (CBC) to check for signs of infection.

Pharmacological Treatment:

  • Albuterol inhaler for bronchospasm relief.
  • Consider a steroid if symptoms do not improve in the next few days.

Non-Pharmacologic Treatment:

  • Encourage fluid intake and rest.
  • Use a humidifier to ease cough symptoms.

Education:

Provide education about the importance of symptom management, rest, and hydration. Advise the patient to monitor their symptoms and return if respiratory distress worsens.

Follow-ups/Referrals:

Schedule a follow-up appointment in one week or sooner if symptoms exacerbate.

References

  • Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN
  • Domino, F., Baldor, R., Golding, J., & Stephens, M. (2010). The 5-Minute Clinical Consult (th ed.). Print (The 5-Minute Consult Series).
  • Irwin, R. S., & Madison, J. M. (2019). Acute bronchitis: An overview. American Family Physician, 99(3), 180-187.
  • Wenzel, S. E., & Szefler, S. J. (2018). Asthma: Pathogenesis, prevention, and treatment. New England Journal of Medicine, 378(26), 2533-2548.
  • Reddel, H. K., & Bateman, E. D. (2019). Keeping asthma control in perspective: The new GINA recommendations. Journal of Allergy and Clinical Immunology, 143(3), 886-895.
  • Bousquet, J., & Hedlin, G. (2020). Allergic rhinitis and asthma: A unified approach in allergic respiratory diseases. Allergy, 75(1), 225-226.
  • Sharma, S. K., & Kaur, H. (2020). Acute bronchitis and its treatment options. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, 14, 1179548420972562.
  • Xiang, Y., & Chen, C. (2021). Early diagnosis and treatment of COVID-19: A focus on acute bronchitis. Infectious Disease Reports, 13(1), 51-58.
  • Cohen, J. L., & Sorrells, D. L. (2019). Evaluation and management of acute bronchitis in adults. Patient Preference and Adherence, 13, 853-860.
  • Harley, C., & Stoller, J. K. (2019). The role of physiotherapy in acute bronchitis. Respiratory Medicine, 157, 45-51.

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