Question

5:56 >< SOAP Assignment #2.docx RC 200 Cardiopulmonary Pathology SOAP Assignment #2 Case Study: Cystie Fibrosis AD The patient had first been seen at the medical center at the age of 22 months, with a history of cough, fever, and runny nose for 7 days. His past history had revealed the production of bulky, foul-smelling stools since infancy. His first upper respiratory tract infection had developed at age 4 months, and he had had a chronic cough and intermitent bronchitis, and otitis media on three separate occasions, always treated with antibiotics. The present illness had been diagnosed as "asthmatic bronchitis, and the patient had been treated at home with antibiotics and expectorants Because the so-called "bronchitis" had not improved, the parents had been advised to bring the child to the hospital. Family history revealed that the parents were healthy but that the only other sibling had cystic fibrosis PHYSICAL EXAMINATION Physical examination revealed an active child in no acute distress but with an almost constant, wet-sounding cough height and weight. The tonsils were boggy and edematous. Coarse crackles and rhonchi could be auscultated over all lung fields. A moderate amount of yellow and opaque sputum was produced with each coughing episode. The chest radiograph revealed atelectasis of the right middle lobe and probable pneumonitis in Laboratory findings showed a hemoglobin concentration of 17 g%, a white blood cell (WBC) count of 21,000, and an Spo, of 90% on room air. The patient's sweat chlonde concentration was 83 mEqL (n- 60 mEq L). A diagnosis of cystic fibrosis was made. At this time, the respiratory therapist was asked to SOAP the patient. Based on these clinical data, how would you SOAP this patient? SOAP 1 Open With

Answer 1

SOPA analysis of this patient is as follows :-

S for subjective data ( chief complaints ) - patient had fever, cough ,runny nose for 7 days .

O for objective data ( vital signs/ physical examination ) - on examination child was active with no distress, wet sounding cough, rectal temperature of 102.3°F, SPO2 - 90% ,abdomen was proturbent . Tonsils were boggy and edematous . On auscultation coarse crackles and rhonchi were present . Sputum was yellow and opaque . X-ray revealed atelectasis of right middle lobe . Suspected pneumonia .

Laboratory investigation results :-

- Hemoglobin concentration of 17%

- WBC - 21000

-sweat chloride concentration of 83 mEq/L .

A ( Assessment ) - on assessment patient was active with no distress , had fever of 102.3 degree fahrenheit and had yellow sputum on coughing.

P (plan ) - X-ray Chest ,laboratory investigation including CBC ,and chloride concentration.