Respiratory Soap Note on Pneumonia
| Name | Pt. Encounter Number: | Time: | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Date: | Age: 66years | Sex: male | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Subjective Data. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Chief complains: “He has a cough accompanied by shortness of breath,” as per the patient’s wife report. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History of presenting illness: The wife reports that he has been exhibiting the symptoms in the past few days and narrates waking up every morning to change the sheets because of being covered with his sweat. She also indicated that he had not had any antibiotics recently. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Medications: The patient is not using any medicines, currently. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Past-Medical History Allergies: No known drug or food allergies. Medication Intolerances: None Chronic Illnesses or major trauma: He has not suffered any chronic illness but suffered a fall which led to a left humerus fracture with a significant injury. Past Surgical History He has no surgical history. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Family History. He is married and practices a monogamous relationship. His family includes two sons, with the first-born son having asthma and a daughter. The other two siblings are alive and well. The patient’s grandmother died of lung cancer ten years ago. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Social History: He never drinks alcohol nor smokes any form of tobacco. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Review of systems. Based on the patient’s condition, it was challenging to obtain comprehensive data. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| OBJECTIVE. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| PHYSICAL EXAMINATION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Vital Signs at 1705HRS | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Weight: 170lbs (77.1kg) | Temperature. 99.8° F (37.6°C) | Bp. 108/ 80mmHg | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Height. 5’9” (1.79 meters) | Pulse. 125bpm | Respirations. 25 rpm | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| O2 Saturation: 95% on 2 liters. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| General: The patient is a confused, ill-appearing male with an abnormally rapid and shallow breathing pattern (tachypneic). Has a warm, dry skin without rashes or lesions.
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| HEENT. His head is normo-cephalic and atraumatic, and no manifestations or lesions on the scalp. For eye examination, the PERRLA with intact extraocular eye muscles based on their movements. The nasal and oral mucous membranes are pink but dry. The neck is supple with a full R.O.M. No cervical lymphadenopathy or occipital nodes are seen. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Cardiovascular. Upon auscultation, the S1 and S2 sound are regular. He has a rapid heart rate (tachycardia) with no murmurs, rubs, or gallops. His capillary refill is two seconds, and peripheral pulses are 2+. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Respiratory. An abnormally rapid and shallow breathing pattern. On auscultation, crackles are heard in the right lower lobe. He presents with labored breathing, which compels him to be unable to form complete sentences. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Gastrointestinal. He has no abdominal scars. Upon palpation, no definite signs of organomegaly were apparent. In all the four quadrants, bowel sounds are present and audible—no abdominal tenderness or softness. There is dullness on the left upper quadrant and tympani in the left upper quadrant, right and left lower quadrants. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Extremities/Musculoskeletal. Expresses equal and full R.O.M. of both the upper and lower extremities. He has a healthy muscle tone with no edema, clubbing, or cyanosis. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Psychiatric. He is awake but confused. Unable to respond to questions since he is tachypneic. Concerning the orientation levels, he remains well oriented to person and place; knows his name and where he is and for treatment (A&O X2). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Laboratory test results at 1726 HRS
Chest X-ray at 1710 HRS A single portable upright anteroposterior view of chest got obtained and compared to that done three months ago. Chest X-ray Results: Airspace opacity in the right lower lobe (RLL). The cardiomediastinal contours are within normal limits. Reasonable amounts of pleural fluids seen. No pneumothorax. A well-healed fracture of the proximal diaphysis of the left humerus is noted. Impression: Right lower lobe pneumonia.
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| ASSESSMENT The patient presents with an abnormally rapid and shallow breathing pattern (tachypneic) and thus unable to form complete sentences. He has a respiration rate of 25 rpm, which exceeds the normal limit of 12-20 bpm. Besides, vital signs indicate a peripheral pulse rate of 2+, suggesting a slightly more diminished pulse than usual according to the 0-4 rating scale. His blood oxygen saturation records 95% on 2 liters per minute flow rate. The patient’s heart rate is 125 bpm, while the normal range is 60-100 beats per minute. He also presents with a fever of 99.8° F.
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| Diagnosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Final Diagnosis/ Impression. Bacterial Lobar Pneumonia (J18.1). According to Hinkle & K.H. (2017), it is a type of pneumonia that presents with an inflammatory exudate (fluid and pus with bacteria and blood cells) in the intra-alveolar space that affects a significant area of the lung lobe(s). The associated risk factors include being elderly, especially people aged above 65 years, lengthy hospitalizations, the young (babies and toddlers), having chronic lung conditions, the immunocompromised, smoking and alcohol taking, and those suffering from recent or current viral infections (Hinkle & K.H., 2017). The patient presents with a fever of 99.8° F, a sign of infection, tachypnea, a rapid heart rate, a cough, and a lot of sweating, which are all clinical manifestations of pneumonia. Besides, he presents with confusion, a common presentation among the elderly aged over 65 years. Diagnosis relies on physical examination with positive findings, including crackles heard in the right lower lobe, as in this case. Also, chest x-ray results act as a confirmatory test; airspace opacity in the right lower lobe indicating bacterial pneumonia. Besides, the lab results indicate infection due to an increased blood count of 14,000/uL.
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| Plan of care. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Based on the CURB-65 Pneumonia Severity Score scale, the patient presents with confusion and aged 66years, thus scores 2 points out of the maximum of 5. This scoring tool is critical for clinicians in deciding the plan of care for any patient presenting with pneumonia, including an appropriate treatment setting (Noguchi, Yatera, Kawanami, et al., 2017). For this case, therefore, the proper disposition for the patient is the inpatient, as the appropriate treatment setting following admission. Further testing: Performing sputum culture, acid-alcohol fast bacilli, and gram staining to identify the specific causative organism. Medication/O.T.C. Recommendations: The patient presents with mild shortness of breath as evidenced by tachypnea, thus supplemental oxygen to be continued using a nasal cannula at a flow rate of 2litres per minute to keep his oxygen saturation above 94% to reduce the work of breathing. Therapy includes an intravenous antibacterial therapy (combined empiric therapy to target therapy) within four hours of presentation for patients being admitted in an inpatient setting. Combined drug therapy, including a 2nd or 3rd generation cephalosporin and Azithromycin a macrolide, is recommended (American Academy of Pediatrics, 2018). IV fluids, including Ringer’s Lactate alternating with Normal saline, administered amounting to 3litres in 24 hours is critical to replace the lost fluids through sweating and cough, and act as a compensatory mechanism to reduce the heart rate (Klepikov, 2017). Dosage: cefotaxime 2g IV, eight hourly and Azithromycin 500mg IV or orally, once daily. Cefotaxime is one of the drugs belonging to the 3rd generation cephalosporin that binds to penicillin-binding proteins and inhibits the final transpeptidation step of peptidoglycan synthesis, leading to cell-wall death. Alternatively, ceftriaxone (1-2g IV, O.D.), ceftaroline (600mg IV, twice daily, or ampicillin-sulbactam (3g IV, four times a day) can be used as a cephalosporin of choice whereas clarithromycin (P.O. or IV 100mg, twice daily) is an alternative macrolide. Drug therapy duration is a minimum of 5 days (Donovan, 2019). P.O. Ibuprofen 400mg, q6hr prescribed as an analgesic and supportive antipyretic therapy. It is a non-steroidal anti-inflammatory drug (NSAID) that inhibits synthesis of prostaglandins in lung tissues by inhibiting two cyclo-oxygenases (COX) isoenzymes, COX-1, and COX-2, thus reducing inflammation and fever. Non-medical management: Positioning the patient in a propped-up position to reduce the risk of aspiration. Suctioning and bronchial hygiene is necessary to decrease fluids in the airway that potentially impair air exchange. Besides, systemic support, including adequate hydration by maintaining enteral and parenteral fluids amounting to 3 liters daily, remains necessary. Adequate nutrition is also essential, and early mobilization as a favorable host milieu to speed recovery (Gamache, 2020). Patient Counselling: Patient counseling is an essential component in providing quality and seamless care in speeding recovery. The patient and the family will undergo reassurance that pneumonia is treatable with recommended therapy. Besides, counseling involves informing them that some less severe types are managed in the outpatient setting and at home. Such will facilitate strict adherence to treatment therapy, thus aiding recovery. Monitoring (Drug and Disease state monitoring): The patient must undergo monitoring for vital signs to check for any fevers following administration of cefotaxime. Also, diarrhea, elevated BUN, eosinophilia, and pruritus are the drug’s side effects requiring monitoring. For ibuprofen, control of common side effects, including dizziness, epigastric pain, heartburn, constipation, nausea, rush tinnitus, headache, and fluid retention (edema). In rare cases, it can lead to acute renal failure and aplastic anemia (Kaysin & Viera, 2016). The disease state is monitored using the blood gas analysis for oxygen requirements, including mechanical ventilation, airway patency to assess the need for suctioning, and vital signs to evaluate the severity of the infection. Monitoring for the complication, including emphysema, is a critical measure. Follow-up: Chest radiograph after six weeks following discharge to ensure resolution of the consolidation and to assess persistent abnormality of the lung parenchyma is critical. Computed tomography is also essential to evaluate recovery. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
American Academy of Pediatrics. (2018). Rethinking Macrolide Use in Inpatient Pneumonia. A.A.P. Grand Rounds, 39(2), 21-21.
Donovan, F. M. (2019, November 10). Community-Acquired Pneumonia Empiric Therapy: Empiric Therapy Regimens. Retrieved April 21, 2020, from https://emedicine.medscape.com/article/2011819-overview
Gamache, J. (2020, March 22). Bacterial Pneumonia Treatment & Management: Approach Considerations, Antimicrobial Therapy for Bacterial Pneumonia, Outpatient Empiric Antibiotic Therapy. Retrieved April 21, 2020, from https://emedicine.medscape.com/article/300157-treatment#d10
Hinkle, J. L., & K.H., C. (2017). Brunner & Suddarth’s textbook of medical-surgical nursing. Vol. 1.
Kaysin, A., & Viera, A. J. (2016). Community-acquired pneumonia in adults: diagnosis and management. American family physician, 94(9), 698-706.
Klepikov, I. (2017). The effect of intravenous infusion on the dynamics of acute pneumonia. E.C. Pulmonology and Respiratory Medicine, 4(2017), 15-20.
Noguchi, S., Yatera, K., Kawanami, T., Fujino, Y., Moro, H., Aoki, N., … & Kohno, S. (2017). Pneumonia severity assessment tools for predicting mortality in patients with healthcare-associated pneumonia: a systematic review and meta-analysis. Respiration, 93(6), 441-450.