2 soaps notes Use Chronic bronchitis soap note 1 Diverticulitis soap note 2 Follow the MRU Soap Note template as a guide Use APA format. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program). Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct
SOAP Note 1: Chronic Bronchitis
Subjective:
The patient, a 65-year-old male, presents with a chief complaint of cough and shortness of breath for the past three months. He reports a productive cough with greenish sputum, which is worse in the morning. The patient denies any chest pain, fever, or chills. He has a significant smoking history of 40 pack-years and is currently still smoking. The patient also reports increased phlegm production and wheezing. He states that these symptoms have been affecting his daily activities, and he is seeking relief.
Objective:
Vital signs: blood pressure 140/90 mmHg, pulse 88 regular, respiratory rate 24 bpm, temperature 98.6°F.
General Appearance: The patient appears mildly dyspneic but in no acute distress. There are no signs of cyanosis or clubbing.
Respiratory: Bilateral wheezing is appreciated upon auscultation. Decreased breath sounds at bilateral bases are noted. No crackles, rhonchi, or rales are heard.
Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs heard.
Abdominal: Soft and non-tender with normal bowel sounds.
Skin: No cyanosis or pallor. No rashes or lesions noted.
Assessment:
Based on the patient’s history, symptoms, and physical examination findings, the patient is diagnosed with chronic bronchitis. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by persistent cough, sputum production, and airflow limitation. It is typically caused by long-term exposure to irritants, such as cigarette smoke. The patient’s significant smoking history further supports this diagnosis.
Plan:
1. Smoking cessation counseling: The patient needs to be strongly advised to quit smoking. Smoking cessation can significantly improve symptoms and slow the progression of chronic bronchitis. The patient will be referred to a smoking cessation program, and nicotine replacement therapy will be considered if appropriate.
2. Chest X-ray: A chest X-ray will be ordered to rule out other possible causes of the patient’s symptoms, such as pneumonia or lung cancer.
3. Pulmonary function tests (PFTs): PFTs will be performed to assess the severity of airflow limitation and to guide management.
4. Bronchodilator therapy: The patient will be prescribed a short-acting bronchodilator to relieve symptoms and improve airflow. The use of long-acting bronchodilators may be considered depending on the severity of the patient’s symptoms and response to initial therapy.
5. Inhaled corticosteroids: Inhaled corticosteroids may be initiated if the patient’s symptoms persist despite bronchodilator therapy or if there is evidence of recurrent exacerbations.
6. Pulmonary rehabilitation: The patient will be referred to a pulmonary rehabilitation program to optimize physical functioning and improve quality of life.
Follow-up:
The patient will be scheduled for a follow-up appointment in two weeks to assess response to treatment, review PFT results, and provide ongoing support for smoking cessation.
SOAP Note 2: Diverticulitis
Subjective:
The patient, a 45-year-old female, presents with abdominal pain and change in bowel habits. She reports experiencing intermittent lower abdominal pain for the past four days. The pain is described as crampy and localized mainly to the left lower quadrant. She has also noticed a change in her bowel habits, with more frequent loose stools. The patient denies any rectal bleeding, fever, or weight loss. She has a history of diverticulosis.
Objective:
Vital signs: blood pressure 120/80 mmHg, pulse 72 regular, respiratory rate 16 bpm, temperature 98.4°F.
General Appearance: The patient appears uncomfortable but in no acute distress. No signs of pallor, jaundice, or rashes.
Abdominal: Tenderness with deep palpation in the left lower quadrant. No rebound tenderness or guarding appreciated. Bowel sounds present.
Rectal Examination: No palpable masses or hemorrhoids. Stool is guaiac negative.
Assessment:
Based on the patient’s history, symptoms, and physical examination findings, the patient is diagnosed with acute diverticulitis. Diverticulitis is an inflammatory condition characterized by infection or inflammation of the diverticula, which are pouch-like protrusions in the colon. The patient’s symptoms, including the left lower quadrant abdominal pain and change in bowel habits, are consistent with acute diverticulitis.
Plan:
1. Bowel rest: The patient will be instructed to follow a clear liquid diet for a few days to allow the bowel to rest and recover. If the patient’s symptoms improve, a low-fiber diet can be gradually introduced.
2. Antibiotics: The patient will be prescribed an appropriate antibiotic regimen to treat the infection. Commonly used antibiotics for diverticulitis include ciprofloxacin and metronidazole.
3. Pain management: Analgesics such as acetaminophen will be recommended for pain relief. The use of non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided due to their potential to worsen inflammation.
4. Instruct patient on warning signs: The patient will be educated on warning signs that indicate the need for immediate medical attention, such as worsening abdominal pain, persistent fever, or development of other concerning symptoms.
5. Follow-up imaging: A follow-up imaging study, such as a CT scan or ultrasound, will be scheduled to assess the response to treatment and identify any complications, such as abscess formation or perforation.
Follow-up:
The patient will be scheduled for a follow-up appointment in one week to evaluate the response to treatment, review imaging results, and provide further guidance on management and prevention of future diverticulitis episodes.