Exam (elaborations) (SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing

Exam (elaborations) (SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing Patient states “I began coughing 1 week ago and its worse at night. My chest is starting to hurt from all of the coughing”. She also is c/o fatigue and getting “winded” while walking daily and no energy to attend her exercise classes. HPI: O: 1 week L: Chest D: 1 week (Have you had these symptoms in the past? If so, what months or seasons?) C: Fatigue, winded, pain in chest (Is your cough dry or productive? Can you describe what the cough sounds like? If your cough is productive, what color is your sputum? Have you noticed any blood in your sputum? Besides your chest hurting, does anything else hurt (throat, sinuses, and ears)? Any chills, body aches, night sweats? Do you hear any wheezing in your chest? Have you felt nauseous, any vomiting or diarrhea? Have you noticed any swelling in your ankles or feet?) A: walking, exercising, worse at night (Does anything else make your cough worse? Eating, drinking?) R: none reported (Does anything relieve the cough?) T: none reported (Have you taken anything for your cough?) S: Severe, affected her daily activities, and sleep. (Can you rate the pain from 0 to 10? Are these symptoms changing your ability to do your normal activities?) Current Medications: Multivitamin, Evista 60 mg daily, HCTZ 25 mg daily Allergies: Demerol, pollen PMHx: Chicken pox, measles and rubella during childhood. Osteopenia, HTN, and hyperlipidemia. Surgical Hx: Tonsillectomy and cholecystectomy. Hospitalized for childbirth and surgeries Social Hx: Lives with husband John, and married daughter and her family. She watches her grandkids when Mary and her husband are at work. Her husband and son-in-law smoke, but not in the house. She does not smoke or drink alcohol. ROS: CONSTITUTIONAL: Reports fatigue. Denies weight loss, fever, and chills. She did not check her temperature. This study source was downloaded by from CourseH on :22:38 GMT -05:00 This study resource was shared via CourseH (SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking) HEENT: Head - No headache, dizziness, or syncope. Eyes – no visual loss, blurred vision, or double vision. Ears – no hearing loss, no ear discharge, or swelling. Nose – no sneezing, congestion, or runny nose. Throat - no report of sore throat, or difficulty swallowing. CARDIOVASCULAR: Reports chest pain. No palpitations or edema. RESPIRATORY: Reports cough and shortness of breath. GASTROINTESTIONAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood in stool. GENITOURINARY: N/A NEUROLIGICAL: No headache or dizziness MUSCULOSKELETAL: N/A HEMATOLOGIC: N/A LYMPHATICS: No reports of enlarged lymph nodes PSYCHIATRIC: N/A ENDOCRINOLOGIC: N/A SKIN: N/A Differential Diagnoses: Pneumonia (ICD-10, J18.9): Community-acquired pneumonia can be either viral or bacterial. S. pneumoniae is the most common cause. S. pneumoniae is a gram-positive organism that naturally lives the upper respiratory tract, colonizes the upper respiratory tract and can cause wide spread invasive infections, pneumonia, upper and lower respiratory infections such as rhinosinusitis and otitis media. Influenza virus is the most common viral cause of pneumonia. The virus destroys epithelial cells and invades goblet cells and bronchial mucous glands, which weaken defenses as sloughing of the bronchial epithelium cells begin. Symptoms begin to show as the body is trying to fight off the invading organisms. White blood cells and other chemicals from the immune system arrive to the site invading the organisms. This will impair oxygenation and produce typical signs and symptoms of pneumonia including; low grade fever, cough, and dyspnea. Others symptoms can include; chills, malaise, and pleuritic chest pain (Severson, Renstrom, & Fitzhugh, 2012). Katie is complaining of a cough for over one week that is worse at night along with chest pain (pleuritic). She also states she is tired and i