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Debra, a 56-year-old female, comes to the clinic complaining of a cold she has had for several weeks that just will not go away. She states she has a dry hacking cough, muscle aches, and a headache. While it is very hot outside, she is shivering with a sweater on. She has tried many over-the-counter medications with no effect. She looks ill and is very fatigued. On chest auscultation, she has some inspiratory crackles and diminished breath sounds. You note some dullness on percussion over her left lower lobe. Her temperature is 100.5°.

 

                                                                                                 SOAP Note

 

Demographics: 56-year-old female

Subjective

Chief Complaint (CC): Persistent cold with a dry cough, muscle aches, headache, shivering, and fatigue for several weeks.

History of Present Illness (HPI)

· Duration: Several weeks

· Quality: Dry, jacking cough; muscle aches; headache

· Associated symptoms: Shivering despite hot weather, fatigue

· Aggravating factors: None specified

· Alleviating factors: None effective, over-the-counter medications tried with no effect effect

· additional information: patient states that the symptoms have persisted despite various treatments.

Questions related to CC:

· Have you experienced any shortness of breath or difficulty breathing?

· Have you had any chest pain?

· Do you have any history of respiratory illness or conditions such as asthma or COPD?

· Have you noticed any palpitations or irregular heartbeats?

· Any swelling in your legs or ankles?

· Have you had any dizziness or light-headedness?

· Any change in vision or speech?

· Have you had any recent weight loss or loss of appetite?

· Have you traveled recently or been in contact with anyone who was sick?

Objective

The patient appears ill and fatigued, wearing a sweater despite hot weather.

Vital Signs:  B/P:     , HR:   , T: 100.5; SaO2:   ; Weight:   ; Height:     ; BMI:

1.  Physical Exam

Respiratory:

– Inspiratory crackles and diminished breath sounds on auscultation, particularly over the left lower lobes

– Dullness on percussion over the left lower lobe

Musculoskeletal:

Muscle aches reported, no joint swelling or erythema

Neurological:

Alert and oriented

2.  Point of Care (POC):

Pulse oximetry

Chest x-ray

 

Plan/Assessment

 

Differential Diagnosis:

1. Viral upper respiratory infection

2. Chronic bronchitis

3. Influenza

4. Tuberculosis

5. Congestive Heart Failure with Pulmonary Edema

WorkingDiagnosis

– Community-acquired pneumonia

Diagnostic Studies:

· Chest X-ray to evaluate for pneumonia or other lung pathology

· Complete blood count (CBC) to check for infection 

· Basic Metabolic Panel (BM) to assess electrolyte balance and renal function

· Sputum culture and sensitivity

· Blood culture 

Treatment:

· Start empiric antibiotic therapy for community-acquired pneumonia (azithromycin or doxycycline): Doxycycline 100 mg PO BID x 7 days.

· Antipyretics and analgesics (acetaminophen or ibuprofen)

· Increase fluid intake and rest

Referral

Patient will be referred to pulmonologist if no improvement  or if condition worsens.

Education

· Patient will be educated on the importance of completing the full course of antibiotics

· Patient will be educated on on recognizing signs of worsening condition (e.g., increased shortness of breath, chest pain, high fever)

· Encourage rest and adequate hydration

Health Maintenance 

We will ensure patient is up to date with vaccinations, including influenza and pneumococcal vaccines

 

Diagnosis

Signs/Symptoms

Gold Standard Diagnostics

Gold Standard Treatment

COPD

Chronic cough, sputum production, dyspnea, wheezing

spirometry

Bronchodilators, corticosteroids, smoking cessation, pulmonary rehabilitation

Community Acquired Pneumonia

Cough, fever, chills, chest pain, dyspnea, fatigue, crackles, dullness on percussion

Chest X-ray, sputum culture, blood culture

Antibiotics (e.g., azithromycin, doxycycline), antipyretics, fluid rest

Atypical Pneumonia

Gradual onset, dry cough, headache, myalgia, fatigue, low-grade fever

Chest X-ray, PCR testing or atypical pathogens

Macrolides (e.g., azithromycin), doxycycline, supportive care

Acute Bronchitis

Cough (may be productive), wheezing, chest discomfort, low-grade fever

Clinical diagnosis, chest X-ray to rule out pneumonia 

Symptomatic treatment (e.g.,antitussives, bronchodilators), hydration, rest

Asthma

Recurrent wheezing, SOB, chest tightness, cough, especially at night or early morning

spirometry, peak flow measurement

inhaled corticosteroids, bronchodilators, leukotriene modifiers

Tuberculosis

Persistent cough (more than 3 weeks), hemoptysis, night sweats, weight loss, fever

Tuberculin skin test (TST), interferon-gamma release assays (IGRAs), chest X-ray, sputum culture

Combination antibiotic therapy (e.g.isoniazid, rifampin, ethambutol, pyrazinamide)

Pulmonary Emboli

Sudden onset dyspnea, pleuritic chest pain, hemoptysis, tachycardia, hypoxemia

CT pulmonary angiography, D-dimer, V/Q scan

Anticoagulation (e.g., heparin, warfarin), thrombolytic therapy, surgical intervention in severe cases

COVID-19

Fever, dry cough, fatigue, loss of state or smell, SOB, body aches, sore throat, congestion

RT-PCR test, antigen test, chest CT scan

Supportive care, antiviral medications (e.g., remdesivir), corticosteroids (e.g., dexamethasone), monoclonal antibodies in certain cases

Upper Respiratory Infection

Nasal congestion, runny nose, sore throat, cough, sneezing, low grade fever, headache, malaise

clinical diagnosis

symptomatic treatment (e.g., decongestants, antipyretics, fluids), rest

Influenza

Sudden onset fever, chills, cough, sore throat, muscle aches, fatigue, headache,, runny or stuffy nose

rapid influenza diagnostic test (RIDT), RT-PCR

Antiviral medications (e.g., oseltamivir), supportive care (e.g., hydration, antipyretics, rest)