When writing a soap note cardiovascular, the response has to clearly, accurately, and thoroughly follow the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned cardiovascular patient. Below is a soap note cardiovascular example
SOAP Note for Case Scenario of an 89- Year Old Male Who Has a History of Smoking 2 Packs of Cigarettes a Day for 7 Decades
Patient Information: XY, 89 years, Gender; Male
CC (chief complaint) Patient has come for a general health evaluation reporting ongoing challenges with belching.
HPI: 89-year-old XY quit smoking cold turkey 11 years ago. He reports experiencing some challenges with belching. During the patient interview, he denies no routine medication and presents with pursed-lip breathing accompanied by a faint whistling sound associated with his respiratory effort, while a review of systems (ROS) reveals he reports a productive cough( with thick clear to white sputum), especially in the morning. He indicates he has shortness of breath (SOB) more than he used to, has coarse breath sounds that are diminished in the lower lobes bilaterally.
Current Medications: No routine medications.
Soc Hx: Chain smoker for 69 years.
Fam Hx: N/A
RESPIRATORY: Utilizes pursed-lip breathing. Sometimes the respiratory effort is accompanied by a faint whistling sound.
\ GENITOURINARY: N/A
Physical exam Soap Note cardiovascular
General Appearance: healthy-appearing
Respiratory- Uses pursed-lip breathing, has breathing with a faint whistling sound, and a productive cough (with sputum thick clear to white sputum
Pulmonary—Has SOB than he used to with breathing sounds that are coarse and diminished in the lower lobes bilaterally
Diagnostic Tests: Spirometry
- Chronic Obstructive Pulmonary Disease(COPD) confirmed
There exist several respiratory diseases and conditions that share symptoms and physical findings with COPD. According to CDC (2012), differential diagnosis of COPD must factor in the symptom complex obtained from the Patient’s history and physical examination findings. The primary features include but are not limited to onset is after the age of 40, presents with abnormal lung function between symptoms and exposure to risk factors as evidenced by 69 years of exposure to first-hand cigarette smoke. Additionally, the Patient’s symptoms worsen gradually as the Patient reports that he experiences SOB more often than he used to. Gupta (2020) reports that spirometry, also known as pulmonary function test is the gold standard for COPD diagnosis.
Furthermore spirometry is accepted as the diagnostic test to assess airflow obstruction and classify the severity of the disease, based on specific cut points for FER (FEV1/FVC <0.7 after bronchodilator) and FEV1 (mild ≥80% predicted, moderate 50-80%, severe 30-49% predicted, very severe <30% predicted). FEV1 normally decreases with age, and the rate of fall is an important spirometry indicator of disease progression in COPD (Burkhardt & Pankow, 2014). Based on these primary features and spirometry results, COPD diagnosis was confirmed
- Asthma (refuted)
Asthma is the main respiratory condition whose symptoms overlap with COPD. In this context, it was considered unlikely as its onset is usually before 20 years, the symptoms vary over time, and its lung function may normally be between symptoms. Moreover, its symptoms tend to be seasonal (Burkhardt & Pankow, 2014). Asthma also has a family history, and its onset is in the early years of an individual’s life.
- Pneumonia( refuted)
Although pneumonia has a productive cough, it was ruled out due to the acute nature of the onset of its symptoms, and chest pain accompanies the breathing or coughing process. The disease is also accompanied by fever, sweating, and shaking chills. Although XY’s advanced age may be a risk factor for pneumonia, the other symptoms helped rule it out.
Pahal et al. (2019) note that the surest to making a correct diagnosis in COPD is to first out ruled out the other causes. Signs of emphysema the Patient is coughing, wheezing, and shortness of breath, and having a whistling sound. However, it was ruled out because the coughing is not frequent while the coughing process produces much mucus.
Since COPD worsens over time, its management in the primary care setting entails routine follow up and monitoring. Spirometry will have to be performed annually to identify whether XY is a case that declines rapidly (Gupta et al., 2020). A questionnaire will be used to conduct the COPD assessment test every three months for symptoms and smoking status at every visit.
The first-line medication is the prescription of inhaled bronchodilators to treat and manage the symptoms and complications of COPD like Albuterol, Ipratropium, or Levalbuterol (Junlaor, 2014), long-acting bronchodilators like Aclidinium are also an option. Inhaled steroids like Fluticasone will be second-line treatment, while combination inhalers and oral steroids like phosphodiesterase will be considered if the COPD becomes severe. Soap Note cardiovascular
Patient education on lifestyle modification like quitting smoking and how to manage the withdrawal symptoms as the Patient quit smoking cold turkey.
The patient needs to consult a respiratory condition specialist to monitor his COPD progression and promptly address any complications. Due to his advanced age, collaboration within a multi-disciplinary healthcare team is needed to treat and manage other chronic diseases whose risk is increased by the presence of COPD. Soap Note cardiovascular
Burkhardt, R., & Pankow, W. (2014). The diagnosis of chronic obstructive pulmonary disease. Deutsches Ärzteblatt International, 111(49), 834.
Centers for Disease Control and Prevention (CDC. (2012). Chronic obstructive pulmonary disease among adults–the United States, 2011. MMWR. Morbidity and mortality weekly report, 61(46), 938.
Gupta, N., Agrawal, S., Chakrabarti, S., & Ish, P. (2020). COPD 2020 Guidelines—what is new and why?. Advances in Respiratory Medicine, 88(1), 38-40.
Junlaor, P., Boontod, V., & Chindavech, N. (2014). Effects of pharmacist interventions to inhalation medication adherence and lung functions in COPD patients at one-stop service clinic. European Respiratory Journal, 44(Suppl 58). Soap Note cardiovascular
Ortiz, M. L. M., & Morera, J. (2012). COPD: Differential diagnosis. Pulmonary Disease-Current Concepts and Practice, INTECH Open Access Publisher, 105-116.
Pahal, P., Avula, A., & Sharma, S. (2019). Emphysema. In StatPearls [Internet]. StatPearls Publishing.
The following questions must be addressed:
- Analyze the subjective portion of the note. List additional information that should be included in the documentation.
- Analyze the objective portion of the note. List additional information that should be included in the documentation.
- Is the assessment supported by subjective and objective information? Why or why not?
- What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
- Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
- Submit your assignment in a Word document. This should be written in a narrative format and not a SOAP note. Focus on answering the questions given to you in the assignment instructions area.
- A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
- Utilize the information provided in the scenario to create your discussion post.
- Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
- Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A] Soap Note cardiovascular
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
- Support the interventions outlined in your ‘P’ with scholarly resources.