SOAP Note; Bacterial Pneumonia

SOAP Note; Bacterial Pneumonia

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SOAP Note; Bacterial Pneumonia

An 82-year-old Caucasian male presented to the emergency department with cough, sputum production, shortness of breath, fatigue, and fever. Because of his comorbidities, he needed immediate hospitalization, comprehensive assessment, skilled nursing management with an interdisciplinary approach of care. The situation necessitated intervention of Clinical Nurse Specialist (CNS) because of specialized holistic approach. The patient is an 82-year-old Caucasian male from a Latino decent. His past medical history include; chronic obstructive pulmonary disease COPD, congestive heart failure, and type 2 diabetes mellitus. He lives his wife at home in the city. They are Baptists and attends church regular but since the onset of his illness, he hasn’t attended church. 

Subjective

Chief Complaint 

The patient presented to the emergency department with a 5-day history of increasing cough (thick yellow-green sputum production), shortness of breath, fatigue, and fever.

History of Present Illness 

The patient is an 82-year-old male who has been experiencing progressive cough, sputum production, shortness of breath, fatigue, and fever in the last 5 days. He claimed to be exhausted all the time and to be unable to finish some of her regular daily tasks without taking long naps. He claimed to have pain in his right side, with characteristics of cough production and pleuritic chest pains. He has a known history of COPD, congestive heart failure, and type 2 diabetes mellitus which increase pneumonia risk. He also notes of decreased respiratory reserve and immune function. Religious affiliation suggests a need for spiritual support because of his advanced age. 

Here is a breakdown;

Onset: 5 days ago 

Location: Right-sided chest pain

Duration: Worsening over 5 days 

Characteristics: Productive cough, pleuritic chest pain 

Aggravating factors: Coughing, deep inspiration 

Relieving factors: None 

Timing: Constant 

Severity: Moderate to severe, limiting activities Associated signs/symptoms: Fever, chills and fatigue

Related systems: No headache, nausea, diarrhea

Past Medical History

Allergies: No known drug allergies 

Childhood Illness: Chicken pox

Adult Illness;

Disease	Period
Type 2 diabetes	Diagnosed at age 55
Hypertension	Diagnosed at age 57
COPD	Diagnosed at age 72
Congestive Heart Failure	Diagnosed at age 80
Benign Prostatic Hyperplasia	Diagnosed at age 80

Injuries: None 

Surgeries: TURP in 2022 for BPH

Hospitalizations: admitted last month for increased cough, sputum production, shortness of breath, fatigue, and fever.

Psychiatric: No history

Health Maintenance: Regularly follows up with PCP

Immunizations: Received MMR (25.1.2015), flu (16.8.2020), COVID-19 (20.6.2021) and COVID-19 booster (20.7.2021)

Dental exams: last dental exam 7 months ago, no issues detected. 

Last eye examination: 3 years ago, wears glasses for reading 

Medications: Over the Couter Medications

Medication	Condition	Dosage	Frequency	Notes
Albuterol	COPD	As needed for symptoms	As needed	Short-acting bronchodilator
Fluticasone/	COPD	Inhalation: Variable	Once or twice	Combination inhaler for COPD management
Salmeterol			daily
Lisinopril	CHF, Hypertension	10-40 mg	Once daily	Adjusted based on response
Furosemide	CHF, Edema	20-600 mg	Once or twice	Taken orally; dosage adjusted based on need
Metformin	Type 2 Diabetes	500-2000 mg	Once or twice	Taken with meals; dosage adjusted as needed
Aspirin	Cardiovascular Risk	81 mg (low dose)	Once daily	Prescribed for specific cardiovascular risk

Prescribed Medication:

Sitagliptin	Type 2 Diabetes	100 mg	Once daily	Taken orally; adjust based on response
Azithromycin	Bacterial pneumonia	Variable	Once daily	Macrolide antibiotic
Levofloxacin	Bacterial pneumonia	Variable	Once daily	Fluoroquinolone antibiotic
Amoxicillin	Bacterial pneumonia	Variable	3 times daily	Beta-lactam antibiotic
Doxycycline	Bacterial pneumonia	Variable	Once or twice daily	Tetracycline antibiotic

Herbals Preparation: None

Family History/ Generic Risk factors: 

Mother (Deceased): CAD, Occasional heart failure  

Father (Deceased): CAD, MI 

Daughter (Alive): AFib, brain CA, CAD, MI 

Wife (Alive): Hepatoblastoma

Personal and Social History 

He is a retired teacher who lives with her wife. Although, he established primary care provider but they feel with his wife at home. During his youthful times, he used to drink alcohol for recreational use. He reports history of smoking but quit because of the advisory from health practitioners. 

Cultural/ Spiritual Considerations 

He was raised a Baptist, and maintains his strong belief in God but his sickness does not allow him to congregate. He married a Baptist and they lead a wonderful life. His sickness makes him depressed, hopeless and displeasured. 

Trusted Nursing Soap Note Writers

Quality of Life Considerations 

Having retired a teacher, he understands responsibility and independence. He is however concerned about his ability to cope with pain from adverse comorbidities, because he is progressively becoming incapacitated. Patient agrees and wants to discuss palliative care options further and actively participate in planning his care. 

Review of Systems: 

General: Appears fatigued, severe respiratory distress

HEENT: Normocephalic, PERRLA, mild jugular venous distension

Cardiovascular: Irregular rhythm, no murmurs, no gallops, pitting edema bilateral lower extremities 2+

Pulmonary: Decreased breath sounds bi-basally, crackles in the lower lung fields

Abdomen: Soft, non-tender, no organomegaly

Extremities: 2+ pitting edema bilateral lower extremities, no cyanosis

Objective

Vitals:

Temp 101.8°F

HR 102

RR 28

BP 142/84

SpO2 89% on room air

Constitutional: Patient exhibited acute distress and fever.

Neuro: Gait is steady and coordinated

Neck: Trachea midline. Thyroid palpated, and nodules and goiters were noted.

Cardiac: Irregular rate and rhythms with minimal respiratory clicks, murmurs, and rubs

Respiratory: Respirations labored with shortness of breath, cough.

Abdominal: Abdomen non-distended. Normoactive bowel sounds in all four quadrants.

Musculoskeletal: few joint pains. No abnormal spinal curvatures.

Skin: Skin is warm and dry; no tenting. No rashes or lesions were noted.

Psychiatric: Patient maintains appropriate attention and affects throughout visit; pleasant;

judgment intact.

Labs:

BNP:	1200 pg/mL (elevated)
BUN:	32 mg/dL (elevated)
Creatinine:	1.5 mg/dL (elevated)
Potassium:	4.8 mmol/L (elevated)
Lab analysis
Lung exam revealed diffuse rhonchi bilaterally.
CBC showed leukocytosis.
CXR confirmed right lower lobe infiltrate.

Assessment and Plan

The assessment and plan for this patient are formulated using nationally validated assessment tools, treatment guidelines/standards and include prescribed medications, therapies, and consultations. 

Assessment:

Differentials Diagnoses

1. Bacterial Pneumonia (J15.9)
2. Acute on Chronic Decompensated Heart Failure (I50.23)
3. Hypertension (I10)

Primary Diagnosis: Bacterial Pneumonia 

Rationale,

Diagnostic Criteria

1. Clinical Presentation

Bacterial Pneumonia (J15.9) occurs when a bacterium enters the lungs and as a result, the body’s inflammatory response causes an inflammation. Generally, the lower respiratory tract system is exposed to these pathogens from the environment. Bacteria proliferation triggers not only an inflammatory response but also fever, leukocytosis and production of purulent sputum. At a later stage, lungs (alveolar spaces) are consolidated impairing gas exchange systems. However, while patients may present bacteria pneumonia differently, common symptoms include; cough often with sputum, fever, chest pain and shortness of breath. 

2. Physical Exam Findings 

Physical exam findings to health practitioners are critical when determining the general status of patients determining the severity of symptoms. The gold standard for diagnosing pneumonia is Chest X-ray (CXR) however, for a more certain diagnosis, physical exam findings are necessary. They include; physical examination where the patient would present fever, crackles and egophony. Other tests include lab and radiology tests. Often patients will present with dullness because of the consolidation of lungs. 

3. Laboratory Findings 

Laboratory diagnosis is critical for early disease, detection, diagnosis and treatment because they work to evaluate bodily functions, monitor disease progression, tract treatment and identify potential complications. In bacteria pneumonia patients, laboratory results will indicate increased Leukocytosis which is a response result of consolidated lungs. Other findings include positive sputum culture due to sputum infection of bacteria. 

Radiographic Findings 

Basically, radiographic findings are critical because they help health practitioners to understand the cause of patient’s signs and symptoms which then will inform both treatment and secondary care. For pneumonia patients, chest Xray is the primary radiography test. 

Bacterial pneumonia (J15.9)  is likely the main diagnosis because of the resembles of acute symptoms which include; productive cough, fever and leukocytosis. Consistent with Streptococcus pneumoniae. Other diagnostic indicators include; Physical exam finding include; Lung exam revealed diffuse rhonchi bilaterally, fever and egophony, Leukocytosis on CBC and Chest X-ray showing confirmed right lower lobe infiltrate.

Acute on Chronic Decompensated Heart Failure (I50.23)

This is less likely because the patient has no orthopnea nor edema or signs which may suggest volume overload. While CXR confirmed right lower lobe infiltrate, there is no indication of perihilar congestion. However, the patient's CHF may have predisposed him to pneumonia. 

Hypertension (I10) 

Elevated BP of 142/82 could reflect undertreated hypertension but this specific indictor does not explain the absence of other main symptoms which include: Nausea, Vomiting, Blurred vision or other vision changes, Anxiety, Heart palpitations and Nosebleed. Critically, hypertension is likely a chronic comorbidity than an acute diagnosis.

To clarify, while the patient had the risk factors similar to those of COPD, CHF and hypertension, the presentation of symptoms points to bacterial pneumonia as the main diagnosis as the current illness. 

Guidelines

IDSA Guidelines: For patients with comorbidities, usage of incentive spirometry and bronchodilators for respiratory support is recommended. Additionally, oxygenation support as needed. This guidelines fronts; Azithromycin, Levofloxacin, Amoxicillin and Doxycycline as first intervention medications for bacterial pneumonia (Charles et al., 2009 & Arntsberg et al., 2024). 

Motivational interviewing to encourage medical drug compliance. 

Plan

The patient will require close monitoring of drug adherence because of his advanced age. Respiratory support to be included such as incentive spirometry, nebulizers, oxygen, and monitoring, as well as supportive care with hydration, nutrition, antipyretics, and DVT prophylaxis. Health literacy especially on pneumonia, drug adherence and preventive measures will be critical using motivational interviewing. Prior to discharge, a repeat chest x-ray will ensure resolving infiltrate and follow-up with his PCP. The follow ups in period of 4 days apart will ensure total antibiotic treatment, respiratory management, and multidisciplinary care.  

References

Arntsberg, L., Fernberg, S., Berger, A.-S., Hedin, K., & Moberg, A. (2024). Management and documentation of pneumonia - a comparison of patients consulting primary care and emergency care. Scandinavian Journal of Primary Health Care, 42(2), 338–346. https://doi.org/10.1080/02813432.2024.2326469 

Charles, P. G. P., Davis, J. S., & Grayson, M. L. (2009). Rocket Science and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) Guidelines for Severe Community-Acquired Pneumonia. Clinical Infectious Diseases, 48(12), 1796– 1796. https://doi.org/10.1086/599227