Debra, a 56-year-old female,
Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.
SOAP Note
Demographics: 56-year-old female
Subjective
Chief Complaint (CC): Persistent cold with a dry cough, muscle aches, headache, shivering, and fatigue for several weeks.
History of Present Illness (HPI):
· Duration: Several weeks
· Quality: Dry, jacking cough; muscle aches; headache
· Associated symptoms: Shivering despite hot weather, fatigue
· Aggravating factors: None specified
· Alleviating factors: None effective, over-the-counter medications tried with no effect effect
· additional information: patient states that the symptoms have persisted despite various treatments.
Questions related to CC:
· Have you experienced any shortness of breath or difficulty breathing?
· Have you had any chest pain?
· Do you have any history of respiratory illness or conditions such as asthma or COPD?
· Have you noticed any palpitations or irregular heartbeats?
· Any swelling in your legs or ankles?
· Have you had any dizziness or light-headedness?
· Any change in vision or speech?
· Have you had any recent weight loss or loss of appetite?
· Have you traveled recently or been in contact with anyone who was sick?
Objective
The patient appears ill and fatigued, wearing a sweater despite hot weather.
Vital Signs: B/P: , HR: , T: 100.5; SaO2: ; Weight: ; Height: ; BMI:
1. Physical Exam
Respiratory:
– Inspiratory crackles and diminished breath sounds on auscultation, particularly over the left lower lobes
– Dullness on percussion over the left lower lobe
Musculoskeletal:
Muscle aches reported, no joint swelling or erythema
Neurological:
Alert and oriented
2. Point of Care (POC):
Pulse oximetry
Chest x-ray
Plan/Assessment
Differential Diagnosis:
1. Viral upper respiratory infection
2. Chronic bronchitis
3. Influenza
4. Tuberculosis
5. Congestive Heart Failure with Pulmonary Edema
WorkingDiagnosis
– Community-acquired pneumonia
Diagnostic Studies:
· Chest X-ray to evaluate for pneumonia or other lung pathology
· Complete blood count (CBC) to check for infection
· Basic Metabolic Panel (BM) to assess electrolyte balance and renal function
· Sputum culture and sensitivity
· Blood culture
Treatment:
· Start empiric antibiotic therapy for community-acquired pneumonia (azithromycin or doxycycline): Doxycycline 100 mg PO BID x 7 days.
· Antipyretics and analgesics (acetaminophen or ibuprofen)
· Increase fluid intake and rest
Referral
Patient will be referred to pulmonologist if no improvement or if condition worsens.
Education
· Patient will be educated on the importance of completing the full course of antibiotics
· Patient will be educated on on recognizing signs of worsening condition (e.g., increased shortness of breath, chest pain, high fever)
· Encourage rest and adequate hydration
Health Maintenance
We will ensure patient is up to date with vaccinations, including influenza and pneumococcal vaccines
|
Diagnosis |
Signs/Symptoms |
Gold Standard Diagnostics |
Gold Standard Treatment |
|
COPD |
Chronic cough, sputum production, dyspnea, wheezing |
spirometry |
Bronchodilators, corticosteroids, smoking cessation, pulmonary rehabilitation |
|
Community Acquired Pneumonia |
Cough, fever, chills, chest pain, dyspnea, fatigue, crackles, dullness on percussion |
Chest X-ray, sputum culture, blood culture |
Antibiotics (e.g., azithromycin, doxycycline), antipyretics, fluid rest |
|
Atypical Pneumonia |
Gradual onset, dry cough, headache, myalgia, fatigue, low-grade fever |
Chest X-ray, PCR testing or atypical pathogens |
Macrolides (e.g., azithromycin), doxycycline, supportive care |
|
Acute Bronchitis |
Cough (may be productive), wheezing, chest discomfort, low-grade fever |
Clinical diagnosis, chest X-ray to rule out pneumonia |
Symptomatic treatment (e.g.,antitussives, bronchodilators), hydration, rest |
|
Asthma |
Recurrent wheezing, SOB, chest tightness, cough, especially at night or early morning |
spirometry, peak flow measurement |
inhaled corticosteroids, bronchodilators, leukotriene modifiers |
|
Tuberculosis |
Persistent cough (more than 3 weeks), hemoptysis, night sweats, weight loss, fever |
Tuberculin skin test (TST), interferon-gamma release assays (IGRAs), chest X-ray, sputum culture |
Combination antibiotic therapy (e.g.isoniazid, rifampin, ethambutol, pyrazinamide) |
|
Pulmonary Emboli |
Sudden onset dyspnea, pleuritic chest pain, hemoptysis, tachycardia, hypoxemia |
CT pulmonary angiography, D-dimer, V/Q scan |
Anticoagulation (e.g., heparin, warfarin), thrombolytic therapy, surgical intervention in severe cases |
|
COVID-19 |
Fever, dry cough, fatigue, loss of state or smell, SOB, body aches, sore throat, congestion |
RT-PCR test, antigen test, chest CT scan |
Supportive care, antiviral medications (e.g., remdesivir), corticosteroids (e.g., dexamethasone), monoclonal antibodies in certain cases |
|
Upper Respiratory Infection |
Nasal congestion, runny nose, sore throat, cough, sneezing, low grade fever, headache, malaise |
clinical diagnosis |
symptomatic treatment (e.g., decongestants, antipyretics, fluids), rest |
|
Influenza |
Sudden onset fever, chills, cough, sore throat, muscle aches, fatigue, headache,, runny or stuffy nose |
rapid influenza diagnostic test (RIDT), RT-PCR |
Antiviral medications (e.g., oseltamivir), supportive care (e.g., hydration, antipyretics, rest)
|
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