Soap Note

SoapNote

SubjectiveAnalysis

Thepatients presenting complaints are in line with the literatureprovision of community-acquired pneumonia. According to varioussources, this type of pneumonia presents with chest pain, which maybe intermittent or sharp, shortness of breath (dyspnea), excessivefatigue, a productive cough with yellowish-green sputum and pyrexia(Robbins, 2012). A headache usually accompanies the symptoms. This isseen in the history of presenting illness, which is almost classical.Most of these signs are usually progressive over a number of days, asdescribed by the patient, especially the shortness of breath (dyspneaon exertion) and excessive fatigue (Robbins, 2012). The painassociated with this type of pneumonia is usually responsive topainkillers, especially NSAIDS, as seen in this case where thepatient is taking ibuprofen. However, the relief is usuallyshort-lived, and the pain comes back. Chicken pox is documented asone of the viruses associated with this type of pneumonia, though inless significance (Robbins, 2012). The patient suffered chicken poxat the age of nine. Smoking also increases the risk of gettingcommunity-acquired pneumonia.

ObjectiveAnalysis

Thistype of pneumonia is associated with fever and chills as seen in theextermination (temperature of 100.40F)(File Jr, 2003). The cardiovascular examination reveals cyanosis,which is in line with written sources. However, though less common,the patient was expected to have a rapid heartbeat. Sometimes, theskin is usually hypothermic, although less common and lesssignificantly. In this case, this feature is absent. This type ofpneumonia does not usually affect nails integrity, and that is whythe patient presents with no deformity (File Jr, 2003)..

AssessmentAnalysis

Asnoted in the assessment, community-acquired pneumonia does notnecessarily necessitate previous hospitalization (Levinson &ampJawetz, 1996). It is acquired through social contact within acommunity setting. In this case, the individuals who have not beenhospitalized develop an infection of the lung parenchyma thatcompromises the function of the lung. This illness affects people ofall ages, and is accompanied by fever, chills, breathingdifficulties, chest pain and a productive cough, just as outlined inthe assessment and various literature sources (Robbins, 2012). Thesesymptoms occur due to accumulation of fluid in the alveolar spaces.As documented in various sources, the causative agents vary fromviruses to bacteria, fungi and parasites. Therefore, as stated in theassessment, there is need to consider multiple organs as one goesabout with the differential diagnosis of this type of pneumonia.Conditions such as pulmonary embolism, congestive heart failure,pulmonary tumors, acute bronchitis, atypical pneumonias andinflammatory lung disease have almost the same presentation. Ahistory of hospitalization should be well outlined to rule outhospital-acquired pneumonia, which also has similar symptoms. Incases of tuberculosis, a positive tuberculin PPD test will behelpful. Hyperinflation on a chest x-ray well to determine if it ischronic obstructive pulmonary disease exacerbation. A chest x-ray isalso useful to rule out a pneumothorax and exacerbation of congestiveheart failure. Smoking is a risk factor as noted earlier. It leads toairway destruction and obstruction, hence fluid accumulation in thelungs (File Jr, 2003).

PlanAnalysis

Asnoted in various sources, community-acquired pneumonia is usuallyaccompanied with leukocytosis, depending on the causative agents.Bacterial agents induce neutrophilia, as compared to parasitic whichinduce eosinophilia. In general, a raised white cell count is asignificant point of reference. It is therefore important to requestfor a CBC count, A WBC count, an ESR and a CRP to check forinflammatory activity in the lungs (Robbins, 2012). A sputum cultureis also recommended ad pointed out in the plan, to confirm thecausative organism. As noted in many sources, a chest x-ray is veryimportant as it will provide information on areas of opacities,showing consolidation. Macrolides such as azithromycin orclarithromycin are important in treatment and management. Inaddition, fluoroquinolones can be substituted (Levinson &amp Jawetz,1996). In this case, the patient is given Clarithromycin 250mg BIDfor 10 days, which is a recommended step. Vitamin C supplementationis also important to prevent immunologic conditions. A follow-up isvery important to assess response to treatment. The Patient shouldalso be counseled and advised on cigarette smoking, as outlined inthe plan, since smoking is a risk factor.

Reference

FileJr, T. M. (2003). Community-acquired Pneumonia. TheLancet,362(9400), 1991-2001.

Levinson,W., &amp Jawetz, E. (1996). MedicalMicrobiology and Immunology: Examination and Board Review.Appleton &amp Lnage.

Robbins,S. L. (2012). RobbinsBasic Pathology.V. Kumar, A. K. Abbas, &amp J. C. Aster (Eds.). Elsevier HealthSciences.