Based on the information provider, the student will follow the SOAP guidelines and complete a narrative report of this case. Remember to research and provide an interpretation for any abnormalities, comorbidities, and medications. Please use this opportunity to learn more about an emerging virus that you may be tasked with treating in the future. Though we do not know much, there is some evidence that will help support your understanding of the disorder and provide guidance on the best treatment options. Please include a description of when the clinical manifestations turn severe and how the provider may then incorporate more critical care strategies (mechanical ventilation). Also, incorporate the role and importance of your clinical competencies from this semester whenever appropriate (which ones are indicated, contraindicated, etc.?).
Clinical SOAP Assignment Guidelines
To earn full credit, the student must do the following |
|
Length |
5-6 pages, not including title page or reference list |
Spelling/grammar APA |
Little to no errors in spelling, grammar, or APA formatting |
Timeliness |
Submitted on or before the assigned due date |
Background information & History of Present Illness |
Described how the patient arrived, what facility the patient is being seen in, the patient’s chief complaint, age and gender. Smoking history in pack years, presence of pulmonary disease, height, weight, IBW, work history or environmental exposure, home oxygen, home medication list, comorbidities |
Subjective information |
Patient or family member responses to practitioner interview |
Objective Information |
Results of physical assessment, vital signs (HR, RR, Temp, Sp02, BP), equipment settings, diagnostic testing. Be sure to include sputum characteristics/culture, CXR or CT results, breath sounds, ABG, lab data, ECG, mental status, PFT, ventilator/Bipap settings, inspection, percussion, palpation, hemodynamic measurements |
Assessment/ professional judgment |
Provide possible explanations or interpretations for each abnormal piece of data collected based on evidence-based practice |
Plan of action |
Provide both the physician’s plan as well as your recommendations for the continued care of this patient; provide rationale as appropriate. Include any relevant therapeutic objectives you wish to obtain. |
Accuracy and completeness of information |
All information should be factual, calculations should be correct, and a thorough description of all medications, conditions, should be included. |
Clinical SOAP Assignment 2
Spring 2020 CPSC 3150
Background Information and HPI
Patient arrival- April 1, 2020 to a local level-1 trauma medical center
Chief complaint(s)- dry nonproductive cough, shortness of breath, general fatigue, loss of appetite, intermittent fever, rhinorrhea
Age and gender- 45-year-old male, Caucasian
Smoking history- never been a smoker
Pulmonary history- no diagnosed lung disease
Height and weight- 5 foot 10 inches, 175 lbs.
Work history- assistant manager at a local grocery store
Home therapy- no home oxygen, Metformin, lisinopril, and atorvastatin
Comorbidities- diabetes, hypertension, and hypertriglyceridemia
Subjective Information
Upon patient interview, the patient disclosed the following:
· Signs and symptoms of illness began four days prior to seeking medical care
· Began as relatively mild but seems to be getting worse
· Cough is strong and frequent but nonproductive
· Feels like he cannot “catch his breath”
· Has not felt like doing much and called in sick to work yesterday
· Some nausea leading to loss of appetite
· Treating low grade fever with Tylenol as needed
· Nasal secretions are clear and watery, patient associates with seasonal allergies
· Patient denies any chest pain
· Has not been wearing a mask to work
Providers perform a thorough physical examination and diagnostic testing.
Objective Information
Physical assessment- patient was alert to person, place, and time; no cyanosis or clubbing noted; no pitting edema present; normal body habitus; no signs of respiratory distress. Inspection, palpation, and percussion revealed no chest abnormalities.
Initial vital signs- BP 135/88, HR 110, RR 16, Temperature 99.5 F, Sp02 95% on RA
ECG- sinus tachycardia
CXR- Initial image on 4/1 demonstrated no acute changes
Bilateral breath sounds- rhonchi was heard bilaterally
ABG- pH 7.39, PaC02 42 mmHg, Pa02 80 mmHg, HC03 24, BE 0 on room air 4/1
Laboratory data- CBC, electrolytes, coagulation testing, liver and renal function panel, C-reactive protein level, and lactate was obtained. The following were considered abnormal:
· Lymphocytes 750/microliter
· Platelets 100,000/microliter
· C-reactive protein 3 mg/L
· Lactate 1.5 mmol/L
The patient was screened for influenza type A and B- both were negative.
The patient was also swabbed for Covid-19 due to potential community exposure with a real time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay (nasal and pharyngeal). The patient was admitted for observation until the results of the assay were confirmed/ruled out and placed in droplet/airborne/contact isolation as a precaution.
The next day the results of the rRT-PCR confirmed the presence of Covid-19 infection. The patient remained stable until repeat examination and diagnostic testing on 4/7 revealed:
Vital signs- BP 140/90, HR 120, RR 28, Sp02 90% on RA
Bilateral breath sounds- crackles/rales heard in both lung bases
ABG- pH 7.35, PaC02 44 mmHg, Pa02 60 mmHg, HC03 22, BE -2 on room air
CXR- bilateral patchy opacities indicative of atypical pneumonia
Physician’s Plan
The patient was placed on supplemental oxygen at 2 liters/min via nasal cannula. The following medications were given while admitted to the hospital:
· Vancomycin
· Cefepime
· Remdesivir
· Guaifenesin
· Acetaminophen
· Intravenous normal saline
Continue to isolate the patient and monitor symptoms of Covid-19. Report incidence to CDC and local health department.
Assessment and Plan
Based on the information provider, the student will follow the SOAP guidelines and complete a narrative report of this case. Remember to research and provide an interpretation for any abnormalities, comorbidities, and medications. Please use this opportunity to learn more about an emerging virus that you may be tasked with treating in the future. Though we do not know much, there is some evidence that will help support your understanding of the disorder and provide guidance on the best treatment options. Please include a description of when the clinical manifestations turn severe and how the provider may then incorporate more critical care strategies (mechanical ventilation). Also, incorporate the role and importance of your clinical competencies from this semester whenever appropriate (which ones are indicated, contraindicated, etc.?).
East Tennessee State University
Soap Example 3
Background Information
Patient originally arrived at the emergency department by ambulance at Bristol Regional Medical Center on April 4th, 2012 after experiencing a fall at Greystone Nursing Facility. After the fall, her saturation was 86% on five liters.
Chief complaint: Patient complained that she had hit her head and could not breathe. She also complained of back and neck pain.
Objective: The patient was given Xopenex at 0.63mg and Pulmicort at 180mcg. Due to her low oxygen saturation and respiratory failure, she was placed on BIPAP as well. However, her saturation continued to drop and her arterial blood gas showed persistent hypoxemia as well as hypercarbia, despite 100% FIO2 on BIPAP, therefore, the decision was made to intubate at that time.
She was also thought to have respiratory failure with a COPD exacerbation and congestive heart failure exacerbation.
The patient was later trached on April 13th, 2012 and moved to Select Specialty Hospital on April 19th, 2012, where she was weaned off of the ventilator and returned to Greystone Nursing Facility.
However, on May 3, 2012, she returned to the emergency department at BRMC as a full code due to cardiac arrest and respiratory failure. She was intubated, moved to the ICU, and later trached and then moved on May 11, 2012 to the IMU at BRMC.
History and Physical
-Co-morbidities:
Co-Morbidity |
Definition |
Treatment/Management |
Hypernatremia |
An electrolyte problem defined as a rise in serum sodium concentration above 145 mEq/l (Lukitsch, 2010). |
Recognizing the symptoms when present, identifying the underlying cause, correcting the volume disturbance, and correcting the hypertonicity (Lukitsch, 2010). |
Anemia |
A condition in which the hemoglobin is below normal (Nabili, 2012). |
Identify the underlying cause, iron supplements, blood transfusions, or Vitamin B12 injections (Nabili, 2012). |
Thrombocytopenia |
Any disorder in which there is an abnormally low amount of platelets (Thrombocytopenia, 2012). |
Treatment depends on the cause of the condition. Usually a transfusion of platelets is required (Thrombocytopenia, 2012). |
Congestive Heart Failure (CHF) |
A condition in which the heart’s function as a pump is inadequate to meet the body’s needs (Kulick, 2012). |
Lifestyle modification, addressing potentially reversible factors, medications, heart transplant and mechanical therapies (Kulick, 2012). |
Obstructive Sleep Apnea (OSA) |
A sleep disorder involving cessation or significant decrease in airflow in the presence of breathing effort (Downey 2012). |
Weight loss, changing sleeping position, avoiding alcohol before bed, CPAP and BIPAP (Downey, 2012). |
Mild Obesity |
The state of being well above one’s normal weight (Definition, 2012). |
Dietary changes, exercise, counseling/support, and medication (Definition, 2012). |
Hypertension |
When a person’s blood pressure is persistently above 140/90mmHg. The cause is often unknown, but it probably is “the result of increased systemic vascular resistance or an increased force on ventricular contraction” (Wilkins, Stoller and Kacmarek, 2009, p.328) |
Making lifestyle changes (those that would affect blood pressure and reduce cardiovascular risk) as well as medications, including diuretics, alpha- and beta-adrenergic blockers, antihypertensives, calcium channel blockers, ACE inhibitors, and vasodilators (Riaz, 2012). |
Gastroesophageal reflux disease (GERD) |
The spontaneous return of gastric contents into the esophagus. The main symptom is frequent heartburn (Heartburn, 2007). |
Medications, lifestyle changes, including eating small, frequent meals, and stop smoking, and possibly even surgery (Heartburn, 2007). |
Chronic Kidney Disease (Stage III) |
Occurs when someone suffers from gradual and usually permanent loss of kidney function over time (Kathuria, 2012). |
Dietary changes, medications, stop smoking, lose weight (Kathuria, 2012). |
Chronic Obstructive Pulmonary Disease (COPD) |
A chronic, ongoing, progressive disease of the lower respiratory tract in the lungs (Treatments, 2012). |
Quit smoking and control symptoms by using medications such as bronchodilators, corticosteroids, and oxygen (Treatments, 2012). |
Type II Diabetes |
A lifelong disease in which there are high levels of sugar in the blood, because the person’s body cannot move sugar into fat, liver, and muscle cells to be stored for energy (Eltz and Zieve, 2012). |
Medication, diet, and exercise (Eltz and Zieve, 2012 |
Hypothyroidism |
A condition characterized by abnormally low thyroid hormone production (Mathur, 2012). |
Synthetic T4 replacement (Mathur, 2012). |
Cardiomyopathy |
A disease that weakens and enlarges the heart muscle (Cardiomyopathy, 2012). |
Depending on which type may include, drugs, surgery, and pacemakers (Cardiomyopathy, 2012). |
-Home Medications:
Drug Name |
Dosage |
Indications |
||||
Acetaminophen (Tylenol) |
650 mg |
Used for mild pain. |
||||
Carvedilol (Coreg) |
6.2 5mg |
Treatment of cardiomyopthy. |
||||
Fluticasone (Advair) |
50mcg |
Used to manage COPD. |
||||
Gabapentin (Gralise) |
100mg |
Used to manage postherpetic neuralgia. |
||||
Levothyroxine (Levothroid) |
75mcg |
Used to manage hypothyroidism. |
||||
Metolazone (Zaroxolyn) |
1mg |
Used to treat hypertension and water retention in CHF. |
||||
Theophylline |
350mg |
|||||
Torsemide (Demadex) |
10- 20mg |
Used to treat edema associated with CHF. |
||||
Levemir (Insulin Detemir) |
35 units |
Used to manage diabetes. |
||||
Coumadin (Warfarin) |
5mg |
Used to treat thromboembolic complications. |
(PDR, 2012)
-Past Surgical History: 1. Automatic implantable Cardioverter-defibrillator placement 2. Tubal Ligation 3. Tonsillectomy 4. Adenoidectomy 5. Cesarean Section 6. Pacemaker placement
-Age: 52
-Gender: Female
-Height: 160.02cm (63in)
-Actual Weight: 102kg (224.4lbs)
-Ideal Body Weight: 45.5 + (2.3 x 63) -60 = 130.4lbs
-Smoking History: 1 pack per day x 25 years= 25 pack years
-Physical Assessment:
-Vitals: (5/11/12): Blood Pressure: 118/90
Pulse: 108
Total Respiratory Rate: 14
Temperature: 37C (98.6F)
Saturation: 92% on 100% FIO2
-General: Patient is awake but does not respond to questions. Pupils are equal, round and reactive to light.
– Neck: No jugular venous distention noted. Has a tracheostomy intact with ventilatory support.
-Lungs: Bruising on left chest area.
-Cardiac: Tachycardiac at 108bpm.
-Abdomen: Has an umbilical hernia. Her bowel sounds are decreased. Abdomen is distended. Percutaneous endoscopic gastrostomy is intact.
-Extremities: She has a left hand small hematoma area. Has a trace of edema in lower extremities and in thigh areas (+2-+3 pitting edema).
-Neurology: Awake but did not mouth any words, just smiled.
-Breath Sounds: Rhonchi and wheezes bilaterally.
-Home Oxygen: Patient uses 3LPM via nasal canula at Greystone Nursing Facility.
-Social History: No history of alcohol or illicit drug use. Stays at Greystone Nursing Facility.
-Previous Pulmonary History: Patient has significant history of COPD.
-Allergies: Patient is allergic to latex. It causes dryness, itching, and burning).
-Chest Radiograph: Taken on 5/11/12. Showed a cardiac pacer, right picc line and tracheostomy. There was improvement in aeration in the right lower lung zone, but there was also development of patchy pulmonary opacities in the right perihilar area and extending into the right apex. Opacities in the left lower lung zone appeared more confluent than previously. Cardiomegaly demonstrated. Pleural effusion may have developed. Co-existing CHF not excluded.
Equipment
The patient needs a ventilator for the time being. Along with the vent, she needs a tracheostomy tube, a tie to secure the tube, a continuous pulse-ox, an HME, a ventilator circuit, a ballard suction catheter and suction canister, materials to perform her trach care, and arterial blood gas kits.
Ventilator Settings
On 5/11/12, her ventilator settings were:
Mode: Assist Control
FIO2: 100%
Tidal Volume: 550ml
Set Rate: 14
Total Rate: 14
PEEP: 5 cmH2O
On 5/17/12, her ventilator settings were:
Mode: SIMV + PS
FIO2: 40%
Tidal Volume: 500ml
Set Rate: 10
Total Rate: 22
PEEP: 5
PS: 10 cmH2O
Diagnostic Testing
Lab Values |
Actual Values |
Normal Range |
Interpretation |
||||
White Blood Cells |
21,000 |
5,000-10,000 |
High |
||||
Red Blood Cells |
3.05 million/cumm |
4-6 million/cumm |
Low |
||||
Hemoglobin |
9. 1g m |
12-16gm |
|||||
Hematocrit |
29.8% |
40-50% |
|||||
Sodium |
147mEq/l |
135-145mEq/l |
|||||
Potassium |
3.6mEq/l |
3.0-5.0mEq/l |
Normal | ||||
Chloride |
105mEq/l |
85-100mEq/l |
|||||
Blood Urea Nitrogen |
44gm/dl |
8-25gm/dl |
|||||
Creatinine |
1.56mEq/l |
0.7-1.3mEq/l |
Interpretation of Diagnostic Testing: The patient’s white blood cell count it extremely high, in return making her red blood cell count, hemoglobin, and hematocrit low. All of these values were checked again on 5/17/12 and most of them were improved. Her white blood cell count was back in normal range, and her red blood cell count, hemoglobin and hematocrit were still slightly under normal range, but improved from 5/11/12.
Arterial Blood Gas
(Taken on 5/11/12)
At the time, the patient was on a ventilator at 100% FIO2.
pH |
7.36 |
7.35-7.45 |
|
PaCO2 |
50mmHg |
35-45mmHg |
Acidic |
HCO3 |
28mEq/l |
22-26mEq/l |
Alkaline |
PaO2 |
60mmHg |
80-100mmHg |
Moderate Hypoxemia |
Interpretation of arterial blood gas: The blood gas is a fully compensated respiratory acidosis with moderate hypoxemia. Another blood gas was done on 5/17/12 and it looked similar to this one so due to her COPD, this probably is not too far from normal for her and should not be worried about too much.
Physician’s Plan
Patient was started on diuretics for her CHF. Lasix was chosen. A bronchoscopy was performed which showed methicillin resistant staphyloccus aureus pneumonia. She was found to be in acute renal failure so nephrology was consulted, her medications were adjusted, and she then had a gradual improvement in renal function. The patient was tried to be weaned off the ventilator but failed so a tracheostomy was placed by Dr. Hoskere on 4/13/12. She also had a percutaneous endoscopic gastrostomy tube placed by Dr. Ampudia. He said she had been having persistent diarrhea with negative clostridium difficle stools a few weeks ago, and decided to start her of Questran. The patient was then transferred to Select Specialty Hospital for continuous pulmonary management as well as medical management. Pulmonary was consulted to decide what her ventilator needs were. She was supposed to have ventilator checks every two hours. She was also ordered to be weaned and adjusted as tolerated. As well as trach care every shift, suction as needed, and to have her ventilator circuit changed once a month. Repeat labs and further workups were also ordered.
-Hospital Medications:
Humalog |
3-15 units |
|||
Lantus |
26 units |
|||
Prilosec (Omeprazole) |
20mg |
Used for treatment of heartburn and other symptoms associated with GERD. |
||
Furosemide (Lasix) |
60mg |
Used as a diuretic due to CHF. |
||
150mcg |
||||
Lisinopril (Prinivil) |
Used to manage hypertension |
|||
Lorazepam (Ativan) |
Used to manage anxiety. |
|||
Metoprolol Tartrate (Lopressor) |
25mg |
|||
Amiodarone (Cordarone) |
200mg |
Used to treat life threatening ventricular fibrillation. |
||
Digoxin (Lanoxin) |
125mg |
Used to treat mild-moderate heart failure. |
||
Fragmin (Dalteparin sodium) |
120 IU/kg |
Prophylaxis of ischemic complications in unstable angina. |
||
Aldactone (Spironolactone) |
Used for heart failure. |
|||
Nexium (esomeprazole magnesium) |
40mg |
Used for treatment and maintenance of erosive esophagitis due to GERD. |
||
Synthroid (Levothyroxine) |
Used to manage hypothyroidism. | |||
Carafate (Sucralfate) |
1g |
Short term treatment of active duodenal ulcer. |
||
ProAir (Albuterol Sulfate) |
4 puffs |
Used to treat bronchospasms. |
||
Flovent (Fluticazone) |
2 puffs |
Used as a corticosteroid. |
||
Zosyn (tazobactam sodium) |
4.5g |
Used for moderate community acquired pneumonia. |
(PDR, 2012)
My Plan
The patient has improved quite a bit from the time she was moved to the IMU on 5/11/12 as far as her ventilator settings go. She is down to 40% FIO2 from 100% FIO2, she is now breathing around twelve times per minute on her own as opposed to not at all before, and she has been able to be switched from assist control mode to SIMV with pressure support. Therefore I would suggest continuing to wean her off of the ventilator. I would first check all of the weaning parameters including her maximum inspiratory pressure, maximum expiratory pressure, vital capacity, and tidal volumes to make sure she fell into the acceptable category. As long as she did, I would start by decreasing her pressure support and PEEP as tolerated. If she continued to do well weaning, I would then start with two hours per day aerosol trach collar weaning trials at around 40% FIO2 to 45% FIO2 and increase it by a couple of hours each day until she could come off of the ventilator completely. Eventually I would suggest she be weaned off of the trach collar as well.
I would also suggest a follow up chest radiograph to find out if there was a pleural effusion that had developed, and if so continue with the necessary treatment of tapping it at the fourth or fifth intercostals space mid axillary.
I think all home medications as well as hospital medications for her co-morbidities should be continued during her stay, especially the Lasix for her congestive heart failure to try and improve the +2 to +3 pitting edema, and the bronchodilators for her COPD.
Regarding the patient’s arterial blood gas, I would not change much because her values are probably very normal for her. Her PaCO2 is elevated but not to an extreme amount and her PaO2 shows moderate hypoxia which is not uncommon for a patient with an obstructive lung disease. I would continue to monitor this, but would not put a lot of emphasis on it unless the values start to change.
Home Care
The patient will not return home but instead to Greystone Nursing Facility, where she was originally brought from before her fall. After she returns, as long as she was weaned and the trach was removed before leaving BRMC, she will need to have stoma care and possibly suctioning through her stoma performed. She will most likely need a small amount of supplemental oxygen as well.
Since the reason she was brought to BRMC in the first place was due to a fall, I would suggest she be placed as a fall risk patient at Greystone and be monitored carefully. I think she would benefit from a walker and working with physical therapy in order to hopefully prevent another fall, and possible intubation.
Her medications for her co-morbidities that she was previously taking before her stay in the hospital should be resumed or continued.
References
Cardiomyopathy. (2012, May 24). Retrieved from
http://www.mayoclinic.com/health
/cardiomyopathy/DS00519/DSECTION=treatments-and-drugs
Downey, R., III. (2012, June 27). Obstructive Sleep Apnea. Retrieved from
http://emedicine
.
medscape.com/article/295807-overview
Definition of Obesity. (2012, June 14). Retrieved from
http://www.medterms.com/script/main/
art.asp?articlekey=4607
Eltz, D. R., & Zieve, D. (2012). Diabetes. Retrieved from
http://www.ncbi.nlm.nih.gov/
Heartburn, Gastroesophageal Reflux (GER), and Gastroesophageal Reflux Disease (GERD).
(2007, May). Retrieved from http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/
Kathuria, P. (2012). Chronic Kidney Disease. Retrieved from
http://www.emedicinehealth.com
/chronic_kidney_disease/article_em.htm
Kulick, D. L. (2012). Congestive Heart Failure. Retrieved from
http://www.medicinenet.com/
congestive_heart_failure/article.htm
Lukitsch, I. (2010, April 19). Hypernatremia Treatment and Management. Retrieved from
http://emedicine.medscape.com/article/241094-treatment
Mathur, R. (2012). Hypothyroidism. Retrieved from http://www.medicinenet.com/
hypothyroidism/page4htm.
Nabili, S. T. (2012). Anemia. Retrieved from http://www.medicinenet.com/anemia/article.htm
PDR. (2012). Retrieved from
http://www.pdr.net
Riaz, K. (2012, January 27). Hypertension Medication. Retrieved from http://emedicine.
medscape.com/article/241381-medication
Thrombocytopenia. (2012, June 28). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/
article/000586.htm
Treatments for COPD. (2012, February 1). Retrieved from
http://www.rightdiagnosis.com/c/
copd/treatments.htm
Wilkins, R. L., Stoller, J. K., & Kacmarek, R. M. (2009). Fundamentals of Respiratory Care.
Missouri: Mosby.