Question

RC 200 Cardiopulmonary Patholozy SOAP Assignment #1 Case Study Bronchiectasis ADMITTING HISTORY A 56 year-old African American woman was acquainted with the medical staft because of frequent episodes of upper respiratory infections The weman worked 40 or more hours per week as a file clerk at a local health department and was known as a hard worker, Despite what she described as her chronic cold. she rarely missed a day of work although she frequently needed to request permission supervisor was a compassionate person and understood the woman's health problem and frequent requests to leave early The woman's hospital chart showed that her respiratery preblems began when she was in her early teens. During that period, frequent upper respiratory tract infections and an annoying cough had been her only symptoms The chart also stated that she had been a smoker of about one pack of cigarettes per day during her teen years Over the years, she had quit and restarted smoking many times. For the previous several years, she had treated herself with acrosolized bronchodilators and kept a humidifier running in her room most of the time. She frequently had been piven antibiotics in alternating cycles Her busband often administered chest percussion and postural drainage at home, and she found this treatment helpful for acute flare-ups (cough and increased sputum production) The woman stated that she had not smoked for 3 months 0ver the previous6 menths, however, she stated that she had lost both weight and her generally "good spirits. She further stated that her cough had been almost continuous, with prodection of copious amounts of foul-smelling, purulent sputum. She denied hemoptysis. She also indicated that her co-workers had become concerned about her condition and recommended that she seek immediate medical attention PHYSICAL EXAMINATION (TIME: 0930) The patient appeared well nourished and complained of severe, nearly constant shortness of breath; a frequent, strong cough; and purulent sputum production She appeared cyanotic, and her fingers and tees showed mild clubbing, She performed episodes produced large amounts of foul-smelling vellow-green sputum. Her vital signs were as follows: blood pressure 185/90, heart rate 110 bpm, respliratory rate 30/min, and oral temperature 37.9 C(1002 F) Palpation of the chest and percussion of the lungs revealed no remarkable abnormalities On auscultation, bilaterall rhonchi and persistent crackles over the lung bases were Examination of her chart revealed mild-to-moderate airway obstruction on pulmonary function tests (PFTs) performed 2 years ago. Her history also showed the following baseline arterial blood gas values (ABGs)en 2 L/min exygen: pH 7.38, Pacou 55 mm Hg, HCO, 33 mEq/L and Paal 68 mm Hg, On this day, her bedside peak expiratery fnow rate (PEFR) was 325 L/min, and her ARG values on 3 L/min 0a by nasal cannula were as follows: pH 752, Paco2 35 mm Hg HCOs 27 mEq/L, and Pao 3 mm Hg Her chest x-ray film revealed changes suggesting cystic bronchiectasis, alveolar hyperinflation, and generalized increased bronchovascular markings Figure 1). The physician called for a respiratery care cenulitation. Based on these clinical data, hoew would you SOAP this patient SOAP

Answer 1

■Subjective

Patient stated the following

• Shortness of breath
• Frequent cough

■Objective

• Cyanosis
• Clubbing of fingers and toes
• Coughing
• Purulent foul smelling sputum
• Pursed lip breathing