Question

i need help with soap assignment The SOAP note (an acronym for subjective, objective, assessment, and plan).
Cardiopulmonary Pathology SOAP Assignment #1 Case Study: Bronchiectasis ADMITTING HISTORY A56-year-old African-American woman was acquainted with the medical staff because of frequent episodes of upper respiratory infections. The woman 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 to leave work early because of doctor appointments. Fortunately, her immediate 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 respiratory problems 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 aerosolized bronchodilators and kept a humidifier running in her room most of the time. She frequently had been given antibiotics in alternating cycles. Her husband 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. Over the previous 6 months, 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 production 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 toes showed mild clubbing. She performed pursed-lip breathing and used her accessory muscles of inspiration. Coughing episodes produced large amounts of foul-smelling, yellow-green sputum. Her vital signs were as follows: blood pressure 185/90, heart rate 110 bpm, respiratory rate 30/min, and oral temperature 37.9° C (100.2" F). Palpation of the chest and percussion of the lungs revealed no remarkable abnormalities. On auscultation, bilateral rhonchi and persistent crackles over the lung bases were heard.

Answer 1

# 1. SOAP analysis :-

S ( subjective data ) - The patient complained of weight loss ,continuous cough with cupious purulent sputum production , shortness of breath

O ( objective data ) - she was cyanoticin look ,her fingers and toes had mild clubbing . The patient used pursed lip breathing and accessory muscles for inspiration. Sputum was foul smelling yellow -greenish in colour .

On examination :-

Temperature was 37.9 degree Celsius

Heart rate 110 beat per minute

Respiratory rate 30bpm

Blood pressure - 185/ 90 mmHg

On auscultation bilateral crackles and rhonchi was present .

A( Assessment ) - on assessment of the patient ,she was having continuous cough with purulent foul smelling sputum. Vitals were :-

Temperature was 37.9 degree Celsius

Heart rate 110 beat per minute

Respiratory rate 30bpm

Blood pressure - 185/ 90 mmHg

On auscultation bilateral crackles and rhonchi was present .

Her peek expiratory flow rate was 325L/min and her ABG values on 3Loxygen by nasal cannula is pO2 -53 mmhg ,pCO2 -35 mmHg , pH - 7.52 ,HCO3 - 27 mEq /l and her X-ray revealed changes suggesting cyctis bronchiectasis ,with alveolar hyperinflation and increased bronchovascular markings .

P( plan) - based on the findings the physicians ordered for a respiratory care consultation.

# 2nd day SOAP analysis :-

S ( subjective data ) - The patient complained of continuous cough with cupious purulent foul smelling yellow - greenish sputum production and it was blood streaked ,shortness of breath was also present .

O ( objective data ) - Her vitals were :-

Blood pressure - 188/ 95 mmhg

Heart rate - 118 bpm

Respiratory rate - 34bpm

Temperature - 37 degree Celsius

SPO2 - 93%

On auscultation , bilateral crackles and rhonchi was present over lung bases.

ABG values were :-

pH - 7.54

pO2 -57 mmhg

pCO2 - 30mmhg

HCO3 - 28mEq/l

A(assessment) - On assessment the patient was having continuous cough with thick purulent yellowish blood stained sputum .Her vitals were :-

Blood pressure - 188/ 95 mmhg

Heart rate - 118 bpm

Respiratory rate - 34bpm

Temperature - 37 degree Celsius

SPO2 - 93%

On auscultation , bilateral crackles and rhonchi was present over lung bases.

ABG values were :-

pH - 7.54

pO2 -57 mmhg

pCO2 - 30mmhg

HCO3 - 28mEq/l

P(plan) - a current chest X-ray was ordered and in that it was revealed density in right lower lobe that was consistent with atelectasis and pneumonia.