Soap Note COPD with Acute Exacerbation of Bronchitis



CC or CHIEF COMPLAINT: Patient reports “increased sputum production and shortness of breath”. She also complains of lacking energy and feeling depressed.

HPI OR HISTORY OF PRESENT ILLNESS: 62 year old white female, 80 kg, who arrives at the clinic with persistent problem of shortness of breath and greater than before sputum production. The patient also complaints about a rash that started on yesterday. In addition to that she also reports energy deficiency, feelings of depression, getting up in the early hours and could not go back to sleep again, a very low desire for food and deficiency of interest in each and everything, i.e. her routine works, and her job for the preceding six weeks.

Though she has more than a few medical troubles, she was all well before this occurrence.

PAST MEDICAL HISTORY: Acute chronic bronchitis derived from smoking. SOB is continuously rising for the preceding two years. The patient hurt her left leg in an accident 7 months back due to which in the calf, a Deep vein thrombosis developed after seven days.

SOCIAL HISTORY:

•Patient is divorced and has no kids and lives alone.

•Smoke two packs of cigarette every day;

•She is a non-drinker.

ALLERGIES:

•Nothing known.

MEDICATION HISTORY:

•Inhaler of Terbutaline four PM and puffs qids for 24 months

•Theodur 600 mg bid for two years

•Warfarin 3 mg qd, initiated seven months back

•Vibramycin 100 mg qd x ten days

•Acetaminophen prn headache

PHYSICAL EXAMINATION:

•GEN - Female of old age in severe suffering

•HEENT - Normal

•VS - HR- 100 bpm, T -37.60C, RR- 32, BP- 120/80 mm of hg, Ht- 5'7”,Wt -80 kg

•CHEST-Numerous wheezes, rhonchi, and rales

•ABD - No organomegaly

•NEURO - Oriented x 3,

•RECT - WNL

•GU - WNL

•EXT - DTRs, NL maculopapular rash on thighs and trunk

LABORATORY TESTS RESULTS:

•Hct -55 (40.7 - 50.3%)

•Alb -4 (3.4 - 5.4 g/dL)

•Na -140 (135 -146 mEq/L)

•K ...