You are seeing S.F., a 74-year-old. Hispanic male in the office this morning for difficulty breathing.
- Background:
- S.F. presents with increased dyspnea on exertion that has become progressively worse over the last 3 days. You observe that he is using pursed lip breathing as he explains his chief complaint. He reports that he has been coughing up a moderate amount of thick, green sputum for approximately one week that was accompanied by a fever of 100.6 and chills. He took Ibuprofen 400 mg every 4 hours and increased his fluid intake for the last week. Two days ago he noticed that the sputum is now yellow rather than green and that he has not experienced any more fever. Overall, he feels like he is getting better. However, the dyspnea on exertion developed three days ago without relief despite the use of his Spiriva HandiHaler. He reports that he lost his rescue inhaler and has not had it to use in over 2 months.
- PMH:
- COPD
- Hypertension
- Osteoarthritis
- Current medications:
- Asprin-81 daily
- Cyclobenzaprine 10 mg prn
- Meloxicam 15 mg daily
- Metoprolol 25 mg daily
- Spiriva HandiHaler daily as directed
- Tramadol 50 mg daily prn
- Surgeries:
- Appendectomy as a child (date unknown)
- 2004-Left cataract extraction with intraocular lens placement
- 2008-Right cataract extraction with intraocular lens placement
- Allergies: NKA
- Vaccination History:
- Influenza vaccine- October 2013
- Pneumovax-2010
- His last TD-can’t remember
- Has not a TDAP/TD in 20 years
- Screening History:
- Last Colonoscopy was 2012-normal
- Last dilated retinal and glaucoma exam was 2013
- Social history:
- Retired roofer-stopped working in 2004 due to arthritis and pain in his rotator cuff. Is married and lives with spouse. They have 4 grown children who live within a 10 mile radius of them. Currently smokes-is down to ½ pack cigarettes daily. Has smoked for 45 years total.
- Family history:
- Father is deceased and had a history of hypertension and diabetes; Mother is deceased and had a history of CAD/MI; Sister-history of colon cancer.
Week 3 Case Study Discussions –SOAP note: Discussion Part One:
- Provide differential diagnoses (DD)with rationale.
- Further ROS questions needed to develop DD.
- Based on the patient data provided, choose geriatric assessment tools that would be appropriate to use in conducting a thorough geriatric assessment. Provide a rationale on why you are choosing these particular tools.
Week 3 Case Study Discussions –SOAP note: Discussion Part Two (graded)
- Physical examination:
- Vital Signs:
- Height: 5’8” Weight: 188 pounds BMI: 28.58 BP: 130/70 T: 99.0 oral P: 72 regular R: 24, pursed-lip breathing; Pain level-7-right shoulder
- HEENT: Normocephalic, symmetric. PERRLA, EOMI, cerumen impaction bilateral ears.
- NECK: Neck supple; non-palpable lymph nodes; no carotid bruits.
- LUNGS: Labored respirations; posterior RLL, LLL, RML, LML diminished breath sounds. Rhonchi right and left anterior chest.
- HEART: RRR with regular without S3, S4, murmurs or rubs.
- ABDOMEN: Normal contour; active bowel sounds, LLQ tenderness.
- PV: Diminished pedal pulses; hair loss noted over extremities.
- NEUROLOGIC: Negative
- GENITOURINARY: Urinary dribbling, urgency, gets up 4 times during the night, distended bladder.
- MUSCULOSKELETAL: Limited ROM in right shoulder. Crepitus in knees bilaterally.
- PSYCH: Negative
- SKIN: Negative
Week 3 Case Study Discussions –SOAP note Discussion Part Two:
- Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 Codes, and plan for follow up.
