SOAP Note For Chronic Cough And Yellowish Sputum Assignment

SOAP Note For Chronic Cough And Yellowish Sputum Assignment

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SOAP Note
Patient information
Patient initials: G.F Age: 46 Race: Caucasian Gender: male
S.
CC:” Persistent cough and yellowish sputum.”
HPI: G.F, a 46-year-old Caucasian male, presented to the clinic with a chief complaint of chronic cough and yellowish sputum. He also reported shortness of breath, chest tightness, and wheezing that exacerbated with exertion. He indicated that these sensations are interfering with his day-to-day activities and that he frequently used a mixture of hot water, ginger, and honey to calm them, but this only provided minor relief. The patient stated that he began having these symptoms 6 months ago. Denies nausea, vomiting, and diarrhea.
Medication: none
Allergies: Allergy: allergic to pollen grain, and Sulphur containing drugs
PMHX: Sinusitis and pneumonia that prompted hospitalizations but was successful managed. SOAP Note For Chronic Cough And Yellowish Sputum Assignment

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Immunization: up-to-date. Last receive flu vaccine 4/2/22
Past surgical history: none reported.
Family history: Family history: mother (72. Y/o): hypertension, father (deceased): stroke maternal grandfather (deceased): COPD. Paternal grandfather(deceased): Hypertension. Paternal grandmother (deceased): Asthma.
Social history: G.F is a part-time lecturer at a nearby institution. He is married to a single woman, and they have a 24-year-old son. He denies using alcohol but confesses to smoking two cartons of cigarettes daily. He stated that he spent the most of his time operating his business in a nearby local market. Exercise once in a while. He is financially secure and has insurance for his family. He always wears his seat belt and avoids using phone while driving. Eat a well-balanced diet that is high in fruits and vegetables.
ROS
General: No fevers, chills, or significant changes in energy level reported.
HEENT: Denies loss of hearing vision, frequent nosebleed, and sore throat.
Cardiovascular: Denies chest pain and dyspnea
Respiratory: Reports chronic cough with yellow sputum, SOB, and wheezes
GI: Denies decrease in appetite, nausea, vomiting, or diarrhea.
GU: Denies urinary urgency and frequency.
Msk: Denies muscle weakness, joint swelling.
Neurologic: stable balance and gait.
Psychiatric: Denies depression or anxiety. Denies homicidal ideation.
Endocrine: Denies heat or cold intolerances
Skin/lymph/heme: Denies skin rash or significant changes in skin color. SOAP Note For Chronic Cough And Yellowish Sputum Assignment
O.
PE
VTS: BP 124/88 left arm, sitting using regular adult cuff. Wt.: 296lb Ht.: 5’6 T.: 37.8 RR: 20 P: 80 Sp02: 98%
General: A&Ox3, appear mildly distress. Well-nourished. Appear his stated age.
HEENT; normocephalic and atraumatic. Visual acuity 20/20, sclera non-icteric. EOMI, PERRLA, no sign of nystagmus. Snares patent bilaterally. Hearing intact with good acuity. No buccal nodule noted. Carotid pulse 2+ bilaterally without bruit.
Cardiovascular: Heartbeat irregular, no murmur, SI and S2 heard and are of normal intensity.
Respiratory: Chest wall is symmetric and non-tender. Yellowish sputum with chronic cough noted.
Skin: Warm and dry. Normal texture
Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.
Extremities: Atraumatic with tenderness. No swelling noted. Muscle strength 5/5 bilaterally.
Neuro: Cranial nerve intact. Sensation intact bilaterally. Memory and thought process intact.
Psychiatric: He is oriented to place and time, no abnormal affect noted.
Assessment:
Lab test and result
Chest x-ray: hyperinflated lungs noted.
Spirometry: result pending
CBC: result pending.
Diagnosis
Differential diagnoses
Chronic obstructive pulmonary disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a kind of obstructive lung disease characterized by long-term breathing issues and decreased airflow. Shortness of breath, wheezing, coughing, and chest tightness are the most prevalent symptoms. COPD is associated to a history of smoking, exposure to environmental pollutants, and genetic variables such as age (Hikichi et al.,2019)SOAP Note For Chronic Cough And Yellowish Sputum Assignment. The illness is distinguished by sputum that may be clear but is commonly yellowish or greenish in color, and the predominant clinical manifestation is shortness of breath after activity. Based on clinical complaints and laboratory testing that confirmed hyperinflated lungs, this is the most likely diagnosis for the client.
Pneumonia
Pneumonia is a catastrophic lung infection that causes fluid to accumulate in the air sacs. This can make breathing difficult and even deadly. Pneumonia is a common complication of COPD that can be hard to identify from COPD exacerbations (Varshni et al.,2019). Coughing up green or yellow mucus and shortness of breath that worsens with activity are also symptoms of pneumonia. It has also been related to unexplained shivering chills, intense perspiration, severe stabbing chest discomfort, and fever that were not evident.

Acute sinusitis
Acute sinusitis is a disorder in which the sinuses become inflamed. This illness is generally brought on by an infection, although it can also be brought on by allergies or other irritants (Wyler et al.,2019). It is distinguished by nasal congestion that makes breathing difficult, thick, yellow or greenish mucus, facial pain, fever, and hyposmia, none of which were present in the client’s instance.
Primary diagnoses: COPD
P.
Lab test: no further lab test is needed.
Medication: Give Ventolin HFA (2 puffs) to be inhaled after every 6 hours to relieve the symptoms.
Patient education: To get the greatest outcomes, the client should be properly instructed on how to use this inhaler. He must be educated of the importance and potential effects of such treatment. He should be advised on the need of stopping smoking because it adds to the progression of COPD. To help manage COPD symptoms, he should be encouraged to get the pneumococcal vaccine (Ignatova et al.,2021). He should be encouraged to eat more fruits and vegetables and to drink plenty of water.
Follow-up: After 6 weeks of therapy, the patient must report back to the clinic for further assessment.
Referral: in case of any complication, the patient should be referred to the pulmonologist for further intervention. SOAP Note For Chronic Cough And Yellowish Sputum Assignment

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References
Hikichi, M., Mizumura, K., Maruoka, S., & Gon, Y. (2019). Pathogenesis of chronic obstructive pulmonary disease (COPD) induced by cigarette smoke. Journal of thoracic disease, 11(Suppl 17), S2129.
Varshni, D., Thakral, K., Agarwal, L., Nijhawan, R., & Mittal, A. (2019, February). Pneumonia detection using CNN based feature extraction. In 2019 IEEE international conference on electrical, computer and communication technologies (ICECCT) (pp. 1-7). IEEE.
Wyler, B., & Mallon, W. K. (2019). Sinusitis update. Emergency Medicine Clinics, 37(1), 41-54
Ignatova, G. L., Avdeev, S. N., & Antonov, V. N. (2021). Comparative effectiveness of pneumococcal vaccination with PPV23 and PCV13 in COPD patients over a 5-year follow-up cohort study. Scientific Reports, 11(1), 1-10. SOAP Note For Chronic Cough And Yellowish Sputum Assignment