SOAP Analysis: Patient Suffering From COPD

SOAP Analysis

Patient Information

Patient YY is a 62-year Asian old man, who regularly checks in within the clinical setting. Dr. A.Z examines YY each time he comes to the hospital setting.

Subjective Data

Chief Complaint

YY complains of elevated levels of release of sputum. The patient has indicated that on several occasions, he has had a release of clear sputum and that the problem was becoming difficult during the night. In addition, YY also complains of a shortness of breath as well as feeling depressed and fatigue or lack of energy. YY has been diagnosed with Chronic Obstructive Pulmonary Syndrome (COPD).

History of Patient Illness

Chest problems: YY is a 60-year-old Asian man who upon arriving arrives at the clinic, complains of having frequent episodes of chest tightness. He reveals that he has a chronic cough which causes production of clear sputum. The levels of sputum release extremely increases during the night while asleep and thus prompting him to clear his throat first thing in the morning due to the excessive mucus in the lungs. He further reports the presence of a certain wheezing sound from his chest and shortness of breath especially whenever he is engaging in physical activities. He explains that the shortness of breath has been persistent for a period of more than one week.

Weight loss: YY complains that there has been a massive decline in his weight. Presently he weighs 80kgs which is a drop from the 90kg weight he was weighing a week ago. This shows a cumulative loss of about 10kgs in a week. He tries to associate this weight loss to the fact that he has had low appetite since the onset of the disorder. He feels that his body has no energy left and is weak to go about his daily routine activities.

Depression: YY reports that he has been moody since the condition began. He states that his energy levels have greatly reduced and he has a constant feeling of getting up early. YY reveals that he has had an acute loss of appetitive. In addition, YY indicates that he has lost a sense of everything including the daily routine that had been part and parcel of his life. YY also reports that he has always felt quite well before the onset of the condition.

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Review of System

Constitutional: YY is a 60-year-old Asian man. There is an acute change in YY’s weight as it reads 80kgs at present but a week ago it had been 90kgs. YY does not show any signs of fever, or chills or malaise. However, he shows fatigability and general body weakness.

Head/face: YY experiences headaches sometimes, especially after frequent coughs. However, he has never had any head injuries, syncope or lost consciousness.

Eyes: The patient shows neither visionary changes nor pain. However, sometimes they do appear bloodshot.

Ears: YY has no hearing loss, no ear pain or any discharge peculiar discharge from the ears. Moreover, the patient does not have tinnitus or vertigo.

Nose: YY is experiencing difficult in exercising his sense of smell. This is due to the excessive amounts of mucus released from the lungs. He sometimes experiences postnasal discharge and sinus pain.

Mouth/Throat/Neck: The patient shows a change is voice, especially it become hoarse from the coughs and excessive mucus. He does not show tooth abscesses, or bleeding gums. He however, has had a change in his taste senses whereby he has no appetite for almost all food types.

Breasts: YY has normal male breasts, with no pain present.

Respiratory: YY experiences frequent chest pains. He experiences shortness in breath especially when he tries to engage in any form exercise. YY produces a wheezing sound whenever breathing. He has a chronic cough that results in production of excessive clear sputum (mucus), especially whenever he attempts to sleep, hence prompting the need to clear his throat every morning to clear the mucus from the lungs.

Cardiac: YY experiences chest pain and increased palpitations. He also shows dyspnoea, claudication and edema. YY has not had any electroradiogram tests carried out on him before, and has no report of his myocardial condition.

GI: The patient has experience d an acute decline in his appetite levels. He hardly feels like eating anything. Nonetheless, the regularity of his bowels is normal, with no present diarrhoea, constipation, jaundice, haemorrhoids or change of stools. YY has not had any previous GI tests carried out on him.

GU: YY does not show presence of any sexually transmitted infections, no pain, no dysuria, no urgency, no nocturia polyuria,or hematuria. The patient also has no dribbling, no hesitancy, loss in force of stream or stress inconsistence.

Reproductive(Male): YY does not have any puberty changes since he is already past that age. He has no erections of unexplained character, no infertility and no pain in the testacies. His libido is just in accordance to his age.

Musculoskeletal: YY has swelling on his feet, legs and ankles. He does not show any joint stiffness, but often complains of feeling week from either side of his legs to an extent he finds it hard to engage in his normal daily routine activities.

Skin/Integument: The patient has a rash on his shoulder which erupted two days ago. He however has not experienced any pigmentation or texture change apart from the lips and fingernail beds.

Psychiatric: The patient is in a state of depression. This explains for his lack of sleep causing him to wake up very early and other disturbed sleep patterns. However, there are changes in concentration, tension, irritability or nervousness detected.

Neuro: YY does not have seizures, syncope, paralysis, abnormalities of coordination and sensation, tremors or memory loss. However, he frequently feels a general body weakness.

Endocrine: The patient has no thyroid enlargement or tenderness, no polydipsia, no diabetes, no polyuria, no changes in body hair and no skin striae. However, he has had an acute decrease in weight.

Hematologic: Lymphatic: YY has no blood cell abnormalities, and also has not had any blood transfusions in the past. Moreover, his lymphnodes are not enlarged or suppurated.

Allergic/Immunologic: YY does not have any allergies he is aware of.

Past History

PMH: YY had acute and chronic bronchitis derived from extreme smoking habits. YY indicated that he had quit smoking a few months ago after being diagnosed with the condition.

PSH: YY also hurt his leg in an accident seven months ago and as a result, he was diagnosed with deep vein thrombosis after he failed to get the requisite treatment. He has undergone one surgery in his 60 years of life.

Past Psychiatric Hx: YY has not in the past suffered from any form of psychiatric disorder.

Hospitalizations: YY was hospitalized seven months ago after he was involved in a car accident where he hurt his leg. He was also hospitalised a few months ago after being diagnosed with acute and chronic bronchitis.

Medications: YY was provided with Terbutaline inhaler and was required to take four puffs for 24 months. In addition, YY had been provided with Theodur 600 mg to be used for two years. Other drugs included warfarin for the treatment of deep vein thrombosis, Acetaminophen for the headache and Vibramycin 100mg.

Allergies: YY indicated no allergies for the drugs or any other kind of food during the entire period he was on drugs.

Dietary Hx: YY has been having a loss in appetite. Of late he hardly eats and this has resulted to a massive decline in his cumulative weight. He has no specific diet restrictions or cultural constraints. He however, loves taking coffee drinks whenever free.

Immunizations: YY has been immunized against Tetanus, Diptheria, Pertussis, Influenza, Measles, Mumps, Rubella and Varicella in accordance to the CDC immunization schedules.

Health Promotion: YY indicated that he had been screened for prostate cancer and the results were negative. Eye exams meant some form of cyanosis where he was advised to seek the necessary help. The dental formulae of YY was in good shape, but nevertheless, YY was previously advised to use calcium supplements to make his teeth stronger.

Functional status: In accordance to the functional ADLs status, YY wakes up early in the morning, walks his dog, takes his breakfast,. i.e. a cup of coffee, goes to work, takes occasional breaks from his work time to grab a snack with coffee, goes back home, walks the dog, has a bath, takes light dinner and goes to sleep. The IADLs here include reading scientific journals and managing resources.

Family History

YY had been orphaned at a very young age and was the first born in a family of four. All the remaining siblings mostly depended on YY while growing up and since YY had lost his job recently, this had an adverse effect on his life. Currently, his two brothers and one sister are doing well as they are all employed and working though they live in the neighboring states. They rarely visit YY and only see each other once after a very long time especially when there is something important in the family that has to be addressed. YY is widowed and has three children who are all married. The three daughters live far away from their father. They call YY on a daily basis to ask about his condition. YY was a heavy alcohol drinker as well as smoker for the past 25 years and only stopped drinking and smoking after his condition grew worse on a daily basis.

YY recently quit his job due to the poor working conditions that he had been subjected though he hopes that he can open up a small business unit where he can retail some products to get some income. YY daughter regularly sends YY with money but had in the previous months complained that their father had returned to drinking despite the poor health condition suffered. YY indicated that he had previously used some of the hardcore drugs while growing up and had been arrested a couple of times while still a young man. YY lives in a small community that is always supportive of his needs and most of the time engage in communal activities that are geared towards educating the young people. YY prefers meeting people and traveling to different parts of the whole world as well as watching the sunset. From the provided information, YY is likely to be suffering from a pulmonary problem that is related to the excessive smoking.

Objective Data

Vital signs

BT: Normal (37.6 C)

PR: Normal (74bpms)

RR: Normal (9bpms)

BP: Normal (120/80)

Oxygen Saturation: 100%

Ht: 5’7’’

Wt: 80kg

BMI: 27kg/m2

Constitutional: There is an acute change in YY’s weight as it reads 80kgs at present but a week ago it had been 90kgs. YY does not show any signs of fever, or chills or malaise. However, he shows fatigability and general body weakness.

General: There is a continual lack of appetite.

Physical Examination:

Chest tests indicate that the patients has rales, rhonchi, and numerous wheezes. YY has no sign of acromegaly while the neurological system can be classified as oriented. The gastrointestinal tests, as well as the rectal test, indicate that everything is within the required limits. YY BMI is within normal limits. Extraocular movements were intact. The head was at the normocephalic states meaning it was atraumatic. The neck was supple with no indication of carotid buit or JVD. The chest had distant breath sounds with no rales and ronchi though there was some form of prolonged expiration. The heart S1and S2 were heard. There was no indication that was any murmurs, gallops or any sort of rubs. In other words, it was tachycardia. The abdomen was non-tender, soft and no bowel sounds were heard. There were no palpable masses within the abdomen. Cyanosis was noted in the eyes though no form of clubbing was identified. Edema was not detected while the psychiatric condition of YY seems to be within range as he maintained eye contact.

Laboratory Results: Haemoglobin level was 12.4 while the white count was 8.4. The plate count was 314,000, chloride 98, sodium 136, potassium 4.5, bicarbonate 36, the creatinine 0.9, troponin levels x2, the BUN levels 18.

Assessment Data

Main Diagnosis

YY is more likely to be suffering from a form of COPD that is referred to as chronic bronchitis which normally involves the release of sputum or any form of mucus from the respiratory systems as well as long term persistent coughs that have been indicated to play a significant role in the development of COPD. Cigarette smoking has been mentioned as the major cause of the condition (Kim & Criner, 2015; Qureshi, Sharafkhaneh, & Hanania, 2014; Vijayan, 2013a, 2013b). YY smoke for long periods, and as a result, it is more likely that the condition developed from smoking. Therefore it is more possible that the type of cough being released by YY is smokers cough. The production of sputum or mucus that is clear, yellowish-gray is an indicator that the condition is related to COPD. In addition, these symptoms are further exemplified by issues such as fatigue, slight chills and fever, chest discomfort, and shortness of breath. Most of the drugs provided in the first case were geared towards ensuring that the effects of chronic bronchitis subsided.

Additional Health Problem

The patient has indicated that he was at one point diagnosed with deep vein thrombosis after suffering a leg injury. Since the leg was not treated on time clots readily developed and as a result pulmonary embolism resulted in deep vein thromboembolism. Warfarin was applied for the treatment and the management of the above condition. Depression has probably occurred due to the effects of chronic bronchitis. These effects have made it quite difficult for YY to adapt to the normal routine since some of the effects of the disease condition have resulted in the decrease of energy levels which are necessary for adapting to the normal state or condition for YY. In addition, the lack of any family member close to providing moral support could ideally be the other major cause of depression.

The nagging cough should be an indicator especially since it has persisted for several weeks. The pain that is associated with a cough is due to inflammatory changes that occur within the body as a result of the immune system attempting to reduce or modify the effects of the above change to the body (Kim & Criner, 2015; Qureshi et al., 2014; Vijayan, 2013a, 2013b). Chronic bronchitis develops gradually from acute bronchitis. Other signs and indications that indicate that the patient is suffering from bronchitis related to COPD include its associated wheezing as well as shortness of breath, the production of discolored mucus, high fever, lack of sleep, and the long lasting coughs (Kim & Criner, 2015; Qureshi et al., 2014; Vijayan, 2013a, 2013b).

Differential Diagnosis

Chronic bronchitis has been shown to share some similar characteristics with the condition. These include acute bronchitis and emphysema. Acute bronchitis is shown in the earlier stages and is considered to develop with chronic bronchitis (Kim & Criner, 2015; Qureshi et al., 2014; Vijayan, 2013a, 2013b). It is commonly associated with the persistent cough provided it has not lasted for three months. It may also show some of the symptoms outlined in chronic bronchitis provided the symptoms have been shown in lesser forms. On the other hand, emphysema has specific characteristics. Most scholars have classified COPD in terms of either chronic bronchitis or emphysema. The condition also develops gradually and affects individuals who smoke cigarettes. Emphysema begins with shortness of breath since the disease commonly begins after the air sacs have been destroyed due to inflammation (Vijayan, 2013a, 2013b). The primary cause of inflammation, in this case, is as a result of smoking or any other genetic condition. Emphysema causes shortness of breath even when an individual is at rest. Other common symptoms associated with the status includes not being mentally alert as well as the fingernails of the patient turning gray or blue (Aggarwal & Dwivedi, 2012; Kim & Criner, 2013).

Risk Factors

Cigarette smoking has been indicated as the most dangerous behavior that is largely associated with the two forms of COPD. Some of the other risk factors associated with COPD include hereditary deficiencies, air pollution, and age. Cigarette smoking has been indicated to play a major role in promoting inflammation of the airway and in the process obstructing the airway causing the shortness of the breath (Aggarwal & Dwivedi, 2012; Decramer, Janssens, & Miravitlles, 2012). Smoking has also been indicated to play a major role in the destruction of cilia which is essential in trapping all the non-required elements from the airway. Immune cells are also affected by the presence of the same cigarette smoke.

Plan

First and foremost, Patient YY has to quit smoking so that the treatment plan becomes more effective and the desired goals are achieved. At the same time, warfarin treatment of deep vein thrombosis should be continued until a point that the medical officer determines that it is fit for the treatment to cease.

The management of chronic bronchitis should take shape or effect. In this case, bronchodilators medications such as aerosols sprays should be taken since they serve to open up and relax the lung openings and in the process reduce the shortness of breaths that has been indicated from the past (Vijayan, 2013b). Antibiotics should also be administered to help reduce the respiratory infections that might have developed over time due to the inflammation of the airway (Kim & Criner, 2015; Qureshi et al., 2014; Vijayan, 2013a, 2013b). Since the patient is already on the use of warfarin, steroid drugs should not be applied since they have the effect of increasing the levels of high blood pressure as well as cataracts and weakened bones systems (Kim & Criner, 2015; Qureshi et al., 2014; Vijayan, 2013a, 2013b). In case the disease conditions had proceeded in higher levels then, it is right for the patient to allow surgical removal of the small wedges of damaged tissues. Last but not least it is necessary that YY be placed on pulmonary rehabilitation which in this case is concerned with the need to educate and counsel the patient. This is required to reduce the elevated stress levels as well as provide methods that could be used to handle the current medical condition. Other important skills or techniques that are to be learned in the rehabilitation period include nutrition counseling, learning new special breathing techniques, and how to cope without smoking. For the treatment of depression, the patient was to be provided with paroxetine as well as enrolling in the above-named support group.

Analysis

Objective and subjective data indicates the patient is suffering from a condition associated with COPD. The two primary features that stand out include the shortness of breath and the increased release of sputum or mucus as well as complaints of chest pains (Kim & Criner, 2013; Vijayan, 2013a). In addition, the patient shows some elevated levels of depression due to the lack of a support system which could have ideally assisted in addressing some of the outlined issues.

COPD is largely associated with two disease conditions: Chronic bronchitis and emphysema. Preferably, acute bronchitis starts before chronic bronchitis and if unchecked or unregulated quickly transforms to the latter. The two disease conditions are largely associated with smoking which damages the airway system due to inflammation and the destruction of cilia. Chronic bronchitis slightly differs from emphysema with the latter focusing on the inflammation and destruction of the air sacs present in the system resulting in the reduced exchange of important gasses that are critical in the respiratory system (Kim & Criner, 2015; Qureshi et al., 2014). In addition, emphysema involves the discoloration of some essential parts of the body and is thus easily differentiated from chronic bronchitis that is widely based on the release of sputum and breathe shortness.