SOAP Note Treatment of COPD

COPD

PATIENT INITIALS:  T.Q       AGE: 55            SEX: MALE    RACE: WHITE

CC: difficulty in breathing and restless. 

SUBJECTIVE: Patient is a 97-year-old female patient who was admitted and treated with COPD exacerbation for pneumonia acquired in the community. The patient does have a long COPD history. She doesn't use oxygen at her private, supported home, though. She made changes yesterday, because she was here at the hospital. She needed some oxygen. She was screened and also qualified for home O2 yesterday. They had really strong lungs. She had bilateral wheezes, and more rhonchi on the right. She seemed a little tired and while she was asking to be discharged home, she did not seem to be fit for it.

OBJECTIVE:
VITAL SIGNS: The patient’s max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106. She is 95% on 2 L via nasal cannula.
HEART: Regular No murmur, gallop or rub.
LUNGS: Reveal no expiratory wheezing throughout. 

ABDOMEN: Soft and nontender. Her bowel sounds x4 are normative.
NEUROLOGIC: She is alert and oriented x3. Her pupils are equal and reactive. She has got a good head and facial muscle strength. Her tongue is midline. She has got clear speech. Her Extraocular motions are intact. Her spine is nontender from neck to lumbar spine on palpation. As with her knees, elbows, wrists and toes, she has a wide range of motion. Her capabilities in the grip are equal in bilateral terms. From extension to flexion both elbows are heavy. Its hip flexors and extenders are both strong and bilateral compatible. Bilateral knee extension and flexion, and ankles are also powerful. Her right knee palpation doesn't show a crepitus. She has suprapatellar inflammation with some bruising and swelling. However, she has a fine joint range of motions.
SKIN: She did have a skin tear involving her right forearm lateral, 

ASSESSMENT:
Acute on chronic COPD exacerbation, generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. 

PLAN:
Obtain an orthopaedic consult secondary to her fall to evaluate her x-rays and function.