Lou Brown’s Soap Note

QUESTION

Please make a SOAP note

Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past two days, he has started coughing up thick pale-yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse. He has also felt very tired. He has taken Tylenol off and on and it does help slightly. About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.

PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.

Medications: lisinopril 20 mg daily; metformin 500 mg twice daily

Allergies: Penicillin

Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.

Vitals: Ht: 5’4″; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%

ANSWER

Subjective

Lou Brown, a 58-year-old white male, presents with a cough that has persisted for the past four days. He describes the cough as intermittent initially but mentions that it has progressed to coughing up thick pale-yellow phlegm over the past two days. He suspects having a fever but has not taken his temperature. Lou is a smoker but has reduced his smoking as it worsens the cough. He also reports feeling tired. He has taken Tylenol sporadically, which provides slight relief. Lou mentions playing poker with sick friends about a week and a half ago but denies any confusion. His wife, who accompanies him, supports this statement.

Medical History

Lou has a history of hypertension and Type 2 diabetes mellitus. He admits not regularly attending medical appointments, with his last visit approximately seven months ago. However, his medications, lisinopril 20 mg daily and metformin 500 mg twice daily, were refilled for a year, ensuring he has an adequate supply.

Allergies

Lou reports an allergy to penicillin.

Social History

Lou has a significant smoking history of 40 pack-years but does not consume alcohol or use drugs.

Objective

Vital signs reveal Lou’s height as 5’4″ and weight as 190 lbs. His blood pressure is elevated at 150/94 mmHg, with a pulse rate of 88 beats per minute and a respiratory rate of 26 breaths per minute. His oral temperature is recorded as 101.0°F. Pulse oximetry shows his oxygen saturation to be 96%.

Assessment

Acute respiratory infection: Lou’s symptoms, including cough with productive sputum, fatigue, and low-grade fever, are suggestive of an acute respiratory infection, possibly bronchitis or pneumonia.
Hypertension: Lou’s elevated blood pressure reading indicates uncontrolled hypertension.
Type 2 diabetes: Lou’s irregular medical follow-up raises concerns regarding the management of his diabetes.

Plan

Respiratory evaluation: Perform a thorough respiratory examination to assess lung sounds, evaluate for signs of consolidation or effusion, and rule out pneumonia. Consider ordering a chest x-ray to further assess the respiratory status.
Symptomatic relief: Recommend over-the-counter cough suppressants and encourage Lou to continue using Tylenol for fever management. Provide guidance on proper medication administration and potential side effects.
Smoking cessation: Discuss the detrimental effects of smoking on respiratory health and offer smoking cessation resources and support.
Hypertension management: Initiate lifestyle modifications, including dietary changes, exercise, and stress reduction. Consider adjusting Lou’s lisinopril dosage or adding antihypertensive medication as necessary.
Diabetes management: Reinforce the importance of regular medical follow-up and blood glucose monitoring. Consider ordering laboratory tests to assess Lou’s glycemic control and adjust his metformin dosage accordingly.
Follow-up: Schedule a follow-up appointment within the next week to review Lou’s respiratory symptoms, blood pressure, and diabetes management. Emphasize the need for regular check-ups and medication adherence.

Education and Counseling

Educate Lou and his wife about the importance of hand hygiene, respiratory etiquette, and proper use of face masks to prevent the spread of respiratory infections.
Provide information on the benefits of smoking cessation, including improved respiratory health and decreased risk of complications.
Discuss the role of lifestyle modifications in managing hypertension and diabetes, including dietary changes, regular exercise, and stress management techniques.

Referrals

Consider referring Lou to a smoking cessation program or support group to enhance his chances of quitting smoking successfully.

Follow-up

Schedule a follow-up appointment within one week to reassess Lou’s symptoms, blood pressure, and diabetes management. Monitor his response to treatment and adjust the plan accordingly.