Soap note for shortness of breath

Subjective Data

Chief Complaint

Patient comes to the clinic with the chief complaints of shortness of breath, wheezing and mild coughing.

HPI

For the last 2 months, patient has experienced asthma attacks on average more than 4 times a week, posttraumatic seizure 2 weeks after the accident and serious MVA 10 weeks ago. Anticonvulsant phenytoin started recently and there has not been any seizure activity since the initiation of therapy.

PMH

Patient has a history of periodic asthma attacks dating back to her early 20s. Three years ago, patient was diagnosed with mild congestive heart failure and placed on hydrochlorothiazide and sodium restrictive diet. Last year, CF placed on enalapril because of worsening CHF. Medication has controlled the symptoms relatively well the last year. Apart from enalapril, other medications prescribed for the patient include albuterol inhaler, theophylline SR capsules 300 mg PO BID, and PRN Phenytoin SR capsules 300 mg PO QHS. She has no known allergies. Patient has not had any surgeries.

Family History

The patient’s parents are both deceased. Her father succumbed to kidney failure at age 59 while her mother died of CHF aged 62

Social History

Patient attests that she is a nonsmoker and she does not consume alcohol. She takes four cups of diet colas and the same number of coffee cups

ROS

Positive for cough, wheezing, exercise intolerance and shortness of breath. Denies seizures, headaches and swelling of extremities

Gen

Pale, well-developed Caucasian female appearing to be anxious. HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted. Abdomen: non-tender, soft, non-distended no masses. Chest: Bilateral expiratory wheezes. Cardio: Regular rate and rhythm normal S1 and S2. Rectal: Guaiac negative. GU: Unremarkable. NEURO: A&O X3, cranial nerves intact. EXT: +1 ankle edema, on right, no bruising, normal pulses.

Objective Data

Vital Signs: BP 171/94, HR 122, RR 31, T 96.7 F, Wt 145, Ht 5’ 3”. After the albuterol treatment, vital signs are BP 134/79, HR 80, and RR 18

Physical Assessment and Diagnostic Testing: Na – 134, K - 4.9, Cl – 100 (all within normal limits), BUN – 21, Cr - 1.2, Glu – 110, Theophylline - 6.2, Phenytoin – 17, ALT – 24, AST – 27, Total Chol – 190 (substantially high, predicted moderate restriction). CBC – WNL, Chest Xray – Blunting of the left and right costophrenic angles, Peak Flow – 75/min (relatively low, normal should be between 80-100/min); after albuterol – 102/min, FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60% (predicted moderate obstruction).

Assessment

1. Chronic obstructive asthma J44.9 (CMS.gov, 2016). Presenting symptoms that match this diagnosis include wheezing, cough, dyspnea/shortness of breath, cough and +1 ankle edema. Previous asthma attacks also place the patient at increased risk of contracting chronic obstructive asthma

2. Emphysema, unspecified J43.9 (CMS.gov, 2016), as evidenced by the patient’s shortness of breath, cough, low FEV1/FVC 60%

3. Bronchitis not specified as acute or chronic. J40 (CMS.gov, 2016) as indicated by the occasional cough, shortness of breath and bilateral expiratory wheezes

Care Plan

A comprehensive care plan targeting the identified diagnoses will help in improving patient care outcomes for the 65-year-old Caucasian female. Patient must receive appropriate instruction pertaining to the possible diagnoses identified. Asthma can be a life threatening condition that causes inflammation and swelling of the airways, making it difficult to breathe. Environmental and genetic factors may play a role in asthma attacks. Bellia & Incalzi (2012) contend that other risks such as air pollution, stress and allergies can trigger asthma attacks. Emphysema on the contrary is a lung disease characterized by reduced airflow and inflammation in the lungs. The reduced airflow results in gradual destruction of the small sacs in the lungs, subsequently manifesting symptoms such as shortness of breath, chest tightness, fatigue, a chronic cough and wheezing. Major risk factors for developing emphysema include smoking, exposure to air pollution and alpha-1-antitrypsin (ATT) deficiency (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013). Bronchitis is also a serious lung disease that occurs due to bronchial tubes’ inflammation. The most common cause of the condition is cold virus, but bacteria can also be the cause in some cases.

The treatment plan prioritizes medications as well as other non-pharmacological interventions. Anticipated outcomes include patient demonstrating improved oxygenation and ventilation, exhibiting effective breathing patterns, maintaining respiratory rate within normal limits and increased control of inflammatory episodes. According to Buttaro et al. (2013), the first line medication for asthma is albuterol, inhaled 1 to 2 puffs every 4 to 6 hours when the patient has breathing complications. Similarly, for emphysema, the primary medication used for reducing dyspnea and improving exercise tolerance is albuterol. Dosage approved by the FDA is 400 µg inhaled twice daily (Bellia & Incalzi, 2012). Other medications to prescribe to the patient will include metaproterenol and levalbuterol (0.2 to 0.3 mL of 5% solution). The medications target various reversible airflow limitations including bronchial smooth muscle contraction, increased airway secretions, bronchial mucosal congestion and airway inflammation. Various medications are also effective for treating bronchitis. Apart from albuterol, the other effective drug for managing the condition is amoxicillin 80 to 90 mg per kg per day taken orally.

Complementary and alternative medicines will also be part of the care plan. Various studies have indicated the efficacy of some herbal remedies in the management of pulmonary conditions such as asthma, bronchitis and emphysema. For example, in a study conducted by Akinci, Zengin, Yildiz, Sener, & Gunaydin (2011), the researchers found out that the most common and effective CAM methods utilized by the participants included deep inhalation, applying vapor, praying and herb or herbal tea. Generally, the patients in this study used CAM to relax, reduce dyspnea, breath comfortably and improve respiration. The researchers also established that these CAM methods had little to no negative side effects (Akinci et al., 2011). Because of the efficacy and safety of the herbal remedies, practitioner will consult with patient to ascertain whether she could implement any of the methods in combination with the medications prescribed. Consulting with the patient also aids practitioner to provide culturally congruent care.

Patient will also receive education on self-care practices that can aid to improve her condition. As the European Respiratory Society (2013) points out, self-care should entail avoiding secondhand smoke, avoiding smoke from fireplaces and avoiding exposure to very cold air. It is also paramount to instruct the patient about the proper use of cough suppressants, OTC fever reducers and pain relievers. Practitioner will further enlighten the patient about the importance of using forward-leaning postures in addition to learning controlled breathing techniques such as purse-lip breathing and abdominal muscle breathing (diaphragmatic breathing). Practitioner will also evaluate the patient’s knowledge pertaining to the use, care and cleansing of nebulizer and inhaler use. According to Bellia & Incalzi (2012), contaminated DPIs, MDIs, diskus, turbuhaler and nebulizer equipment are typical causes of infections.

Apart from the practitioner, other helping professionals will also provide care to the patient. For example, human service professionals will help patient in looking for possible assistance/community resources while spiritual leaders will offer nourishment to ensure that the patient receives holistic care. Referring the patient to psychiatric specialists is another component of the care plan that will help ease her anxiety and mild stress. Involving CF’s family members is also critical. Buttaro et al. (2013) acknowledge that warmth and cohesiveness in the family environment improves resiliency and provides a coping mechanism for the patient.

Follow-Up Plan

Follow-up will entail appropriate monitoring of patient’s vital signs following discharge. First follow up scheduled after 4 weeks. During the session, practitioner will conduct comprehensive physical examinations and diagnostic tests including spirometry, methacholine challenge test and chest x-rays to check the prognosis of disease (European Respiratory Society, 2013). Patient to share information about any side effects or allergies associated with the medications she is taking. Appropriate measures will be taken to ensure adherence, compliance and improved outcomes.

References

Akinci , A., Zengin , N., Yildiz , H., Sener , E., & Gunaydin , B. (2011). The complementary and alternative medicine use among asthma and chronic obstructive pulmonary disease patients in the southern region of Turkey. International Journal of Nursing Practiceq, 17(6), 571-582.

Bellia, V., & Incalzi, R. (2012). Respiratory diseases in the elderly (3 ed.). Sheffield: European Respiratory Society Journals.

Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care : a collaborative practice (4 ed.). St. Louis, Mo.: Elsevier/Mosby.

CMS.gov. (2016). ICD-10. Retrieved from https://www.cms.gov/medicare/coding/icd10/index.html

European Respiratory Society. (2013). Respiratory diseases in the world: Realities of today – opportunities for tomorrow. Retrieved February 12, 2017, from https://www.ersnet.org/pdf/publications/firs-world-report.pdf