Episodic/Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Episodic/Focused SOAP Note
Patient Information:
Ms. V, 71, F
S (subjective)
CC (chief complaint): Weak and tired all the time. Coughing and sneezing and headaches over the eyes and a chill. Worried and cannot sleep at night.
HPI (history of present illness): Ms. V is a 71-year old female of unknown ethnicity who comes to the clinic complaining of weakness and general body fatigue. She is complaining of coughing and sneezing and headaches over the eyes and a chill. She is worried and cannot sleep at night.
Current Medications:
HCTZ 25 mg daily
Losartan 50mg daily
Lexapro 10 mg daily
MVI daily
Calcium 18 mg daily
Melatonin 6 mg nightly
Tylenol 10 mg every 6 hours as needed for pain
Oxygen concentrator for shortness of breath
Inhaler at night
Allergies:
No known drug allergies
PMHx:
High blood pressure
Asthma
Soc and Substance Hx:
Non-smoker, no alcohol use, or illicit drug use. She is a retired housekeeper. She baby sits her grandchildren 3 and 10 years old. Grandparents and parents all died of old age.
Fam Hx:
Grandparents and parents all died of old age.
Grandchildren have no significant medical history.
Surgical Hx:
None
Mental Hx:
No history of depression or anxiety
Violence Hx:
None
Reproductive Hx:
Not sexually active. She is in menopause.
Immunization:
Vaccinated against Covid-19 with two doses. Booster shot not yet.
ROS (review of symptoms):
• GENERAL: Coughing and sneezing a chill. Lack of sleep due to worry.
• HEAD: Headache over the eyes.
• EENT (eyes, ears, nose, and throat): No swelling or discharge, no blurred or double vision, no running nose, and no sore throat.
• RESPIRATORY: Coughing.
• CV: Denies
• GI: Denies N/V/D
• GU: No changes in urinary patterns.
• NEURO: NO dizziness but headache over the eyes. No changes in body movement and memory patterns. No history of seizure or problems with coordination.
• LYMPH/HEME: Denies
• ENDOCRINE: Denies
• MUSCULOSKELETAL: Back pain reported.
• HEMATOLOGIC: No bleeding or anemia.
• LYMPHATICS: No history of splenectomy.
• PSYCHIATRIC: No history of depression.
• ENDOCRINOLOGIC: No reports of sweating or heat intolerance.
• REPRODUCTIVE: Not sexually active.
• Allergic/immunologic: No history of rhinitis but she has asthma.
O (OBJECTIVE)
Physical exam:
Vital signs: Temperature: 98.6, Pulse 78, RR 18, BP 112/72, Weight 172lb Height 5’10
Diagnostic results:
Chest CT scans
Polymerase chain reaction (PCR) test
CBC
A (assessment)
Differential diagnoses:
Covid-19
Covid-19 affects people differently and the symptoms can be from mild to severe. Some of the common symptoms include fever, fatigue, coughing, loss of smell and taste (Felsenstein et al., 2020). Others include headache, sore throat, diarrhea, and skin rash. Difficulty in breathing and chest pain. The patient is likely suffering from the condition due to her age and history of asthma (Felsenstein et al., 2020). She requires urgent help to alleviate the risk of adverse outcomes.
J45. 909 Asthma
The second most likely condition is asthma, due to the history of an asthmatic condition. The patient may be suffering from a reoccurrence of the disease. A step-wise method is used to treat the condition to provide the needed immunity against the disease (Calzetta et al., 2021). Some symptoms include difficulty in sleeping, breathing, exhaustion, and drowsiness.
J18. 9 Pneumonia
Patients with pneumonia include chest pain, coughing, fatigue, fever, nausea, and vomiting. Patients with asthma are likely to suffer from pneumonia, especially during the cold season (Calzetta et al., 2021). Appropriate interventions are vital to alleviate the risk of death.
J09. X2 Influenza
Influenza causes symptoms such as fatigue, coughing, fever, muscle and body aches, and running nose. Patients with asthma and Covid-19 are required to take a test for influenza since it is a fatal disease (Lansbury et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers).
J12. 2 Parainfluenza
Parainfluenza refers to a family of viruses called the human parainfluenza viruses (HPIVs). The disease is among the Paramyxoviridae family (Lansbury et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). The symptoms include coughing, fever, running nose, and rattling at the chest or back.
J81. 0 Cardiogenic edema
Cardiogenic edema causes symptoms related to Covid-19. Individuals should get tested to confirm the exact condition they are suffering from. Some symptoms include excessive shortness of breath, dizziness, anxiety on lying down (Ingbar, 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). The condition occurs due to increased pressure in the heart.
J67. 9 Hypersensitivity pneumonia
Hypersensitivity pneumonia causes shortness of breath, dry cough, fatigue, fever, and chest tightness. The condition occurs due to an allergic reaction (Salisbury et al., 2017).
415.19 Pulmonary infarction
Pulmonary infarction is a condition that causes chest pain, body weakness, coughing, and fever. A CT scan is vital for diagnosis. Immediate treatment of the condition is critical (Salisbury et al., 2017).
P (plan)
Treatment of Covid-19 is critical due to escalating severity within a short time. Despite the level of severity, a pharmacological interventions is critical. One of the vital interventions is to check the oxygen level and pulse rate. Oxygen support is necessary if the patient is experiencing difficulty in breathing. The patient should continue taking current medication and get medical support for asthma. The patient should take pain killer to avert pain. If the symptoms persists, an MRI will be critical in providing a detailed image of the respiratory system.
Eating a healthy meal is critical for the patient to improve the general fitness of the body. Eating healthy meals is a strategy for maintaining body fitness. It improves body health and prevents conditions such as weak immunity. Weak immunity is a major factor that can complicate the body’s health and cause stress on the body.
A referral to a specialist in Covid-19 will be critical for the recovery of the patient. Working with a respiratory therapist can increase the chances of recovery.
It is vital to educate the patient on the disease, role of eating healthy meals, and avoid transmission. A patient should receive oxygen support in the ICU if the condition worsens. Educating the patient on adherence to the medication is crucial for recovery. The patient should adhere to the medication and report after two weeks.
The patient should come for follow-up care after two weeks or before depending on the recovery process. The follow-up care may take even a month depending on the improvement. Coordination of care among the different specialists is critical for recovery. Appropriate interventions should be taken depending on the outcome.
Reflection
The case study of the patient is an eye-opener since it provides new insights into the different diagnostic tools and differential diagnoses. I learned that accuracy in the provision of care for patients with respiratory conditions such as Covid-19 is vital for recovery. I learned that patients start treating conditions involving pain by taking over-the-counter drugs. An examination of the drugs a patient is taking is critical in the determination of the drugs a patient should start taking.
An evaluation of the patient’s lifestyle is critical for the recovery and prevention of similar conditions in the future. For instance, the patient should avoid heavy tasks that involve straining the body. The patient should stay active since bed rest is not the best intervention for patients with Covid-19. It is vital to educate the patient to get a booster shot, keep mask on, and avoid crowded places. Going for a walk is a strategy of being active.
During the provision of care, adherence to ethical considerations in nursing is critical in the delivery of patient-centered care. Patients of unknown ethnicity should receive quality care without any form of discrimination. Justice in nursing involves the observation of fairness in the delivery of care (McDermott-Levy et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Veracity involves telling the truth to the patient. For instance, telling the patient about the causes of Covid-19 and other conditions that lead to fever, pain, coughing, and fatigue will help adjust lifestyles (McDermott-Levy et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). A nurse practitioner should utilize the best knowledge available in treating the patient. nonmaleficence involves the provision of care while taking utmost care to avoid harm (McDermott-Levy et al.,2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Ethical practice is safe for patients and improves the level of confidence in patient outcomes.
References
Calzetta, L., Matera, M. G., Coppola, A., & Rogliani, P. (2021). Prospects for severe asthma treatment. Current Opinion in Pharmacology, 56, 52-60.
Felsenstein, S., Herbert, J. A., McNamara, P. S., & Hedrich, C. M. (2020). COVID-19: Immunology and treatment options. Clinical immunology, 215, 108448.
Ingbar, D. H. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Cardiogenic pulmonary edema: mechanisms and treatment-an intensivist’s view. Current opinion in critical care, 25(4), 371-378.
Lansbury, L., Rodrigo, C., Leonardi‐Bee, J., Nguyen‐Van‐Tam, J., & Lim, W. S. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Database of Systematic Reviews, (2).
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Ethical principles and guidelines of global health nursing practice. Nursing outlook, 66(5), 473-481.
Salisbury, M. L., Myers, J. L., Belloli, E. A., Kazerooni, E. A., Martinez, F. J., & Flaherty, K. R. (2017). Diagnosis and treatment of fibrotic hypersensitivity pneumonia. Where we stand and where we need to go. American journal of respiratory and critical care medicine, 196(6), 690-699.
