NRNP 6665 Comprehensive Focused Soap Note
Week (enter week #): (Enter assignment title)
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Assignment Due Date
CC (chief complaint): NM is a 16-year old male with a history of bronchitis, who reports to the outpatient room with, complains of productive cough for one week, shortness of breath that developed late last night, and fatigue for close to a week.
HPI: The symptoms have been worsening over the stay, with severe exhaustion on little exertion. The patient reports to have developed the cough 1 week ago, and visualized yellowish/green sputum, which comes with feverish feeling that she manages with chlorphenamine that she purchased over the counter. After experiencing severe shortness of breath last night while going upstairs, he decided to step into the hospital for check-up.
Substance Current Use: He denies any use of alcohol or smoking.
- Current Medications: He reports to be using chlorphenamine which he bought over the counter to mange fever.
- Allergies: He has no know food or drug allergies.
- Reproductive Hx: He denies being married or having any child. His reports to be sexually inactive at his age.
- GENERAL: His general appearance portrays an athletic on heavy clothing not congruent with the weather.
- HEENT: He has no headaches or dizziness. Has no tinnitus or hearing loss. The nose is congested, with rhinitis, but has no epistaxis. His throat is dry and sore, with painful swallowing. No neck swellings.
- SKIN: The skin is free from rashes or jaundice
- CARDIOVASCULAR: No tachycardia or any cardiovascular disease.
- RESPIRATORY: Shorteness of breath, sputum discharge, respirarions above 32b/min, no chest pains.
- GASTROINTESTINAL: . Has no reports of nausea, vomiting, diarrhoea or reduced appetite.
- GENITOURINARY: Has no dysuria or hematuria.
- NEUROLOGICAL: GCS 15/15
- MUSCULOSKELETAL: He has optimal joint range of motion, no reports of mucle pain or numbness on extremities.
- HEMATOLOGIC: No signs of hypercoagulation or bleeding disorders.
- LYMPHATICS: Has no oedema on either limbs.
- ENDOCRINOLOGIC: No history of diabetes or hyperthyroidism.
His T-102.9, P-95, R-37, BP-118/84, PO2-93% off oxygen and BMI-19.4. His chest Xray indicates congested lungs.
Mental Status Examination: NM is a 16-year old athletic, appropriately dressed, clean and groomed. He has no signs of abnormal muscle movements. His speech is clear, audible and coherent. His thought process is logical, with no sign of disturbed throught content. He has an appropriate affect congruent to his mood. He denies any form of auditory, visual, tactile, olfactory or taste hallucinations. He also denies any sign of suicidal ideations, attempts or plans. He is alert and active, with optimal concentration.
Diagnostic Impression: With the report of rapid onset and high fevers, typical pneumonia is a probable diagnosis. His chest Xray indicating congested lungs also support the diagnosis. Coloured sputum also acknowledges a bacterial pneumonia (Sattar & Sharma, 2021). Right sided heart failure is contraindicated by absence of jugular distension or any oedema on the peripheries. High fevers were an indication of present infection. Differential diagnoses include pulmonary embolism and congestive heart failure (CHF) (Htun et al, 2019). The former is supported by shortness of breath, although ruled out by the present progression of symptoms. The patient also lacks any risk to hypercoagulation or jugular distension. The latter is supported by cough, shortness of breath and family history of hypertension. However, the chest X-ray supports a normal ventilation perfusion process. Lack of oedema or jugular distension helps to rule out heart failure.
Reflections: I agree with the present diagnosis of pneumonia. Although symptoms are flu-like, the period of progression andsevere shortness of breath indicate a possible severe infection in the lungs. The American Thoracic Society recommends use of high dose amoxillin and clavulanic acid for patients with recent history of using amoxicillin. However, although eliminating a specific causative agent is difficult, an additional sputum culture could be advised, to guide the line of antibiotic therapy.
Case Formulation and Treatment Plan:
The medical plan of care will resume albuterol to open his airways hence resolve the shortness of breath. Amoxicillin with clavulanic acid oral dose is recommended as first line (Mantero et al, 2017). A non-steroidal anti-inflammatory drug such as ibuprofen also helps to reduce throat pain and possible inflammation. Oxygen supplementation may be indicated on need basis. The patient is also encouraged to increase fluid intake, and lots of vitamin foods (Nayar et al, 2019). The patient is also asked to report back in case of shortness of breath while at home.
NRNP 6665 Comprehensive Focused Soap Note References
Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Scientific reports, 9(1), 7600. https://doi.org/10.1038/s41598-019-44145-y
Mantero, M., Tarsia, P., Gramegna, A., Henchi, S., Vanoni, N., & Di Pasquale, M. (2017). Antibiotic therapy, supportive treatment and management of immunomodulation-inflammation response in community acquired pneumonia: review of recommendations. Multidisciplinary respiratory medicine, 12, 26. https://doi.org/10.1186/s40248-017-0106-3
Nayar, S., Hasan, A., Waghray, P., Ramananthan, S., Ahdal, J., & Jain, R. (2019). Management of community-acquired bacterial pneumonia in adults: Limitations of current antibiotics and future therapies. Lung India : official organ of Indian Chest Society, 36(6), 525–533. https://doi.org/10.4103/lungindia.lungindia_38_19
Sattar SBA, Sharma S, (2021). Bacterial Pneumonia. StatPearls Publishing; Available from: https://www.ncbi.nlm.nih.gov/books/NBK513321/