Case Study

Mr. John Doe is a 5’7”, 79-year-old man who came to the hospital because he had been “feeling sick with a bad cough” for the past five days. He had a bad cough that brought up yellowish mucus, along with a fever and shortness of breath. He felt more tired than usual, had no appetite, and was sweating a lot at night. His fever would rise to about 101°F, and he noticed it was harder to breathe when walking or climbing stairs. He didn’t have any chest injuries or cough up blood, but he did have a dull pain in the right side of his chest that wouldn’t go away. He does not complain of nausea or vomiting but states he has had diarrhea today.

Mr. Doe is a retired mechanic who worked in a factory for many years, often around dust and fumes. He also smoked a pack of cigarettes every day for 45 years but quit about ten years ago. In addition to his smoking history, he has chronic breathing issues (COPD), high blood pressure, type 2 diabetes, and high cholesterol. His family history includes a father who passed away from lung disease at age 72 and a mother who died of cancer at 80. He has an older brother who is 82 and has heart disease and high blood pressure. Mr. Doe lives alone in a single-story house, and his two adult children live in other states. He takes lisinopril 10mg, atorvastatin 20mg, and aspirin 81mg at home. He is allergic to nuts and Sulfa.

Upon admission, Mr. Doe was found to be in mild respiratory distress, using accessory muscles to breathe. His vital signs included a temperature of 101.2°F, heart rate of 98 bpm, and respiratory rate of 22 breaths per minute. His oxygen saturation was 89% on room air, prompting the initiation of supplemental oxygen at 2L/min via nasal cannula. On physical examination, he appeared fatigued but alert, with decreased breath sounds and crackles noted over the right lower lung field. There was dullness to percussion and increased tactile fremitus in that area, suggesting consolidation or possible pleural effusion.

Lab results showed an elevated white blood cell count of 14,000/μL. His basic metabolic panel was largely unremarkable, except for a mildly elevated glucose of 130 mg/dL. Other lab results were as follows: Sodium 138 mmol/L, Potassium 4.0 mmol/L, Chloride 99 mmol/L, Bicarbonate 22 mmol/L, BUN 16 mg/dL, and Creatinine 1.0 mg/dL. The arterial blood gas on 2LNC was ph 7.45/PaCo2 36/PaO2 65/HCO3 23. A chest X-ray showed a right lower lobe infiltrate and revealed blunting of the right costophrenic angle. He was started on ceftriaxone 1g IV and azithromycin 500 mg IV in the ED. He was also given a Duoneb 2.5mg.

Using the case study above or one that your instructor provides to you, draft a complete SOAP note using the following template, save your SOAP note as a separate Word document and upload to your designated LMS assignment.

SOAP Note

Name:        Date:        Gender:     Age:           Height:      Weight:

SUBJECTIVE 

CC:

HPI:

PMH:

FH:

SH:

OBJECTIVE

ALLERGIES:

HOME MEDICATIONS (list all home medications – in table format):

DIAGNOSTIC TEST RESULTS (list all other testing here):

ASSESSMENT 

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3.

PLAN

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