12Academic Clinical SOAP Note

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Academic Clinical SOAP Note
Subjective
Chief complaint
A 62 years old male was brought to the ED by his wife with a
three-day history of short breathing, wheezing, grunting, nose
flaring, productive cough, and gradual change in the color of
sputum from yellow to brown (Fermont et al., 2020).
Primary working diagnosis
· COPD acute exacerbation (J44.1)
Acute exacerbation of chronic obstructive pulmonary disease
manifests a sudden worsening of coughing symptoms, wheezing,
fatigue, color, quantity, and sputum consistency. These
symptoms typically last for several days and cause extreme
discomfort to the patient.
Pending differential diagnosis
· Asthma (J 45.901)
· Congestive heart failure (150.20)
· Pneumothorax (J 93.9)
· Pleural effusion (J 90)
· Pulmonary embolism (126.99)
· Cardiac arrhythmia (149.9)
History of present illness

The patient has been experiencing short breathing for the last
two years, and it has been getting worse for the past four days.
The patient is positive for dyspnea on exertion. The patient has
reported fever, chills, night sweats, chest pain, and palpitation.
Moreover, the patient has signs of lower extremity edema.
However, the patient was rather uncomfortable because of
labored breathing. He has been using different kinds of inhalers,
yet he has not completely recovered from the cough. He has
been hospitalized multiple times for acute COPD exacerbations.
The diagnosis is made based on present medical history,
breathing profile, and spirometry results. FEV1/FVC ratio was
0.68 (68%). The ABG test indicated that the oxygen saturation
is not satisfactory, the values are, PaO2 = 58, PaCO2 = 30,
Arterial blood PH = 7.32, SaO2 = 86. The patient has a long
history of smoking, and he is a chain smoker. He is not an
alcoholic and does not use any illicit drugs. He needs urgent
hospitalization for oxygen therapy.
Past medical history
· Hypertension (I10)
· Emphysema (J 43.9)
Past surgeries
· Hernia repair surgery (K 46.9)
· 2-day hospitalization
· Multiple hospitalizations for COPD
Family history
· Mother died of heart failure
· Father had COPD
· Brother has hypertension
· Sister is normal
Medication
· Lisinopril 20 mg BD
· Atorvastatin 20 mg BD
· Salmeterol 250/50 inhaler, two puffs daily
· Albuterol nebulizer every 8 hours daily
Hypertension
· Lotensin 40 mg OD

· Zestril 20 mg OD
Emphysema
· Duakril inhaler two puffs daily
Review of systems
Constitutional symptoms
Fatigue, 20 LB weight loss. Slight weakness, no fever, no night
sweats.
The patient seemed fatigued, and he stated that he lost 20 LB
weight during the last six months. However, the patient had no
fever, and no sweating was observed.
Eyes
No obvious visual changes.
The color of the sclera was normal. Upon investigation, the
patient said that he did not feel any visual problem. The
diagnosis has no negative effect on ocular microvasculature.
Retinal oxygen level is normal.
ENT
No epistaxis, no sinus pain, no odynophagia.
The patient denied any sort of nasal bleeding and sinus pain.
The negative impact includes slight voice change sore throat
due to persistent cough.
Cardiovascular
No edema, no palpitations, no chest pain.
The COPD exacerbation negatively impacts the heart rate. The
heart rate increased slightly after some physical activity and the
patient felt breathing problems.
Respiratory
Cough, sputum, wheezing, short breathing, exercise intolerance.
The patient indicated his major complaint as the presence of
crucial symptoms such as persistent wheezing, change in color ,
and consistency of sputum.
Gastrointestinal
No abdominal pain, no indigestion, no bloating, slight nausea
due to productive cough.
The patient indicated that he felt bloated right after a meal. The
patient said that he felt slight nausea after coughing.

Genitourinary
No dysuria, hematuria, or polyuria.
No obvious genitourinary problems were observed. The patient
mentioned that he had not any kind of difficulty in passing
urine. Moreover, he did not indicate the presence of polyuria.
Musculoskeletal
No muscle pain, however, a slight decrease in the range of
motion.
As the patient is 62 years old, he has slight disorientation and
limited body motion. However, he did not indicate muscular
pain. There is slight joint pain due to aging.
Integumentary
Cyanosis present on extremities.
Upon examination, there was slight cyanosis on the tips of
fingers. Moreover, the color of the lips was also slightly blue.
Neurological
No headache, no seizures, no faints.
There were no neurological problems reported by the patient.
The patient did not indicate blackout, headache, spasms, and
convulsions.
Psychiatric
Slight anxiety due to breathing problems.
The patient presented no psychiatric problems. However, the
patient was slightly nervous and uneasy due to breathing
problems.
Objective
Vital signs
Temperature: 98.56, Heart Rate: 78, Blood Pressure:110/82,
Respiratory Rate: 10, Weight, 58 kg, Height: 5ft 5 inches.
Physical examination
General
Slight weight loss due to stress-induced by labored breathing.
· Positives: anxiety, disturbed sleep pattern
· Negatives: confusion, fainting
The physical examination shows slight weight loss, pale skin,
and cyanosis on the fingers. However, no lumps and bruises

were present.
HEENT
No headache, normal sclera, intact oral mucosa, intact ear canal.
· Positives: sinus problem, nasal obstruction
· Negatives: eye pain, double vision
The head is atraumatic and normocephalic. Extraocular motility
and alignment are normal. Slightly swollen neck arteries. There
is no gingival bleeding. No oropharyngeal abnormalities were
present.
Respiratory
Cough, wheezing,
· Positives: short breathing, exercise intolerance
· Negatives: hemoptysis, dry cough
The shape of the chest was slightly barreled. The wheezing and
paradoxical abdominal movement was present. Moreover, there
was an increased expiratory time.
Cardiovascular
No palpitations,
· Negatives: chest pain, oedema.
The patient was intolerant to physical exercise and breathing
sound rather diminished. At the beginning of inspiration, coarse
crackles were heard.
Gastrointestinal
No abdominal pain.
· Positives: nausea, loss of appetite
· Negatives: hematemesis, hematochezia
The belly was slightly swollen due to bloating and constipation.
Integumentary
· Positives: cyanosis, dry skin
· Negatives: pruritus, eczema
The skin was slightly dry, and there was cyanosis on the fingers
and lips.
Extremities
· Positives: Slight clubbing, cyanosis

· Negatives: edema
Slight clubbing of fingers was present. Additionally, the patient
said that he had cyanosis for the past three months.
Neurological
Normal body posture and no headache.
· Positives: anxiety, sleep patterns
· Negatives: fainting, special senses
The patient was active and conscious. However, he was slightly
nervous due to breathing problems.
Lab investigations
1.ABG (82803)
PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86.
2.COPD assessment test (96417)
CAT score: 30
3.Sputum examination (87077)
o Yellow to brown color sputum
o Increased growth of Gram-negative and Moraxella
catarrhalis
4.WBC (005025)
o 14000 cells/microliter
5.HB (85018)
14.1
6.Hematocrit (85014)
o 47 %
Imaging diagnostic tests
1.Spirometry (94010)
o FVC: 2.28 L
o FEV1: 1.56 L
o FEV1/FVC: 0.68
2.Chest X-Ray (71020)
o Dark pulmonary field
o The flattened diaphragm on the lateral view
o Increased air in the retrosternal area
o AP diameter increased
o Bullae present on both lungs
3.Ct scan (74178)

o Centrilobular emphysema
o Thick bronchial wall
o Small airway obstruction in both lungs
o Slightly narrow trachea at the coronal plane
o Pulmonary hypertension
Assessment
Acute diagnosis
Bronchiectasis (J 47.9)
This is an obstructive lung disorder that is often associated with
a genetic cause. Bronchiectasis can occur alone or with COPD.
However, the major difference is the age as Bronchiectasis
occurs in early childhood.
Congestive heart failure (150.20)
The symptoms are related to COPD such as cough, wheezing,
fatigue, and weakness. Short breathing is also a major symptom
of congestive heart failure; therefore, it is often associated with
COPD.
Tuberculosis (15.7)
TB is a highly contagious lung disorder with pertinent
symptoms of weight loss, fatigue, persistent productive cough,
short breathing. All these symptoms are closely related to
COPD.
Chronic diagnosis
Asthma (J 45.901)
Asthma is one of the most common differential diagnosis of
COPD. Both diseases have more or less the same symptoms.
Long-term asthma results in COPD at later ages. Therefore, I
prioritize asthma on my list of differential diagnoses.
Chronic bronchitis (J 42)
The disease's etiology is different from COPD; however, the
symptoms are more or less the same. These include short
breathing, wheezing with thick and increased mucus production.
Emphysema (J 43.9)
One of the major risk factors of COPD is emphysema. It is
caused by long-term smoking or smoking from a very early age.
The disease affects the alveolar sacs and damages them causing

a severe type of cough and prolonged degeneration of the
tissues (Ono et al., 2020).
Differential diagnosis eliminated
· Bronchiectasis (J 47.9)
· Chronic bronchitis (J 42)
Plan component
A treatment plan that corresponds with the diagnosis.
COPD needs effective treatment and management based on
individualized assessment. Pharmacotherapy would be
influential in reducing the symptoms and frequency of
exacerbation.
Provide information on admission type
The patient must be admitted to a healthcare facility to receive
medication therapy based on certain bronchodilators to curb the
symptoms.
Types of diagnostics
All the pertinent diagnosis is performed, such as AGB, CAT, to
assess airway obstruction severity.
Prescribed medications and dosages
Medication therapy
· Vibramycin 100 mg BD
· Levaquin 500 mg OD
· Long-acting bronchodilators beta2 agonist are preferred
because the severity of obstruction is high (Gold C)
· Inhaled corticosteroid is the other treatment option for a
patient with a severe form of COPD. The ICS also manages
frequent exacerbation.
· Phosphodiesterase 4 inhibitors are also used in patients with
COPD exacerbation with a long history of emphysema or
chronic bronchitis.
· Individualized treatment is used in COPD exacerbation that is
based on GOLD guidelines. Certain antibiotics are also added to
secure treatment goals.
Oxygen therapy
· Long term oxygen therapy is used for COPD, and when the

patient experiences severe hypoxia to improve his life
expectancy, sleep, cognitive and physical performance.
· Pulmonary rehabilitation
· Noninvasive ventilation (Nunez et al., 2020)
Relevant consults or follow-up procedures needed
· Smoking cessation
· Assessment of symptoms control
· Reassessment of inhaler using technique
· Assessing the time for the need for referral
· Spirometry assessments
· ABG assessment
Ethical considerations
Ethical considerations are the principal ethics that allow the
patient to make his decisions, autonomy, beneficence, and Non-
Malfeasance
legal considerations
The healthcare system's legal consideration includes advance
directives, confidentiality, and informed consent regarding his
treatment.
Geriatric considerations
The geriatric patients are particularly more vulnerable to the
adverse implications of the COPD acute exacerbation. COPD is
generally a very common disorder in older patients; therefore,
geriatric considerations are crucial in this context. Similarly,
there is a high mortality and morbidity rate in older patients,
and they cannot follow routine medical treatment. Appropriate
care must be provided, including regular medication, proper use
of an inhaler, nebulizers, physical exercise, and moral support.
References
Fermont, J. M., Bolton, C. E., Fisk, M., Mohan, D., Macnee,
W., Cockcroft, J. R., ... & Wilkinson, I. B. (2020). Risk
assessment for hospital admission in patients with COPD; a
multi-centre UK prospective observational study. PloS one,
15(2), e0228940.

Nuñez, A., & Miravitlles, M. (2020). Preventing readmissions
of COPD patients: more prospective studies are needed.
Ono, M., Kobayashi, S., Hanagama, M., Ishida, M., Sato, H.,
Makiguchi, T., & Yanai, M. (2020). Japanese patients' clinical
characteristics with chronic obstructive pulmonary disease
(COPD) with comorbid interstitial lung abnormalities: A cross-
sectional study. PloS one, 15(11), e0239764.
Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsANP-650ANP-650-XO0103XBAcademic
Clinical Discharge Summary
Note65.0CriteriaPercentageExcellent
(100.00%)Content70.0%Reason for Admission and Full
Diagnosis10.0%A description of the reason for admission, a list
of diagnoses in order of acuity, and an ICD-10 diagnosis are
extremely thorough and include substantial supporting
details.All Procedures10.0%A list of all dates, significant
findings, any anesthetics, and contrast used during procedures is
present.Consults During Hospitalization10.0%A complete list of
consults during hospitalization, including any providers or
services consulted during stay is present.Condition of Patient at
Discharge10.0%A physical exam prior to discharge that
documents patient is stable at discharge and has safe disposition
and transportation is present.Discharge Medications10.0%A full
list with all dosages, frequencies, and quantities of medications
prescribed or dispensed is present.Tests for Follow-Up10.0%A
complete list of any pathology, cultures, radiology, or other
diagnostic tests still pending and who is responsible for follow -
up on final results is present.Listing of Discharge Follow -
Ups10.0%A complete list of discharge therapies, treatments,
referrals, consults, and follow-up appointments is
present.Organization and Effectiveness20.0%Mechanics of
Writing (includes spelling, punctuation, grammar, language
use)20.0%Writer is clearly in command of standard, written,
academic English.Format10.0%Paper Format (Use of

appropriate style for the major and assignment)5.0%All format
elements are correct.Documentation of Sources (citations,
footnotes, references, bibliography, etc., as appropriate to
assignment and style)5.0%Sources are completely and correctly
documented, as appropriate to assignment and style, and format
is free of error.Total Weightage100%
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Academic Clinical Discharge Summary Note
Muhammad Aftkhar
Grand Canyon University
February 15th, 2021
Reason for admission
A 62 years old male patient came with a dull throbbing pain in
the right upper abdominal region. The patient was somewhat
nervous due to stabbing pain. The pain scale was eight. The
patient reached the hospital with his daughter. Upon physical
examination, there was swelling on the upper right abdomen and
pain radiating towards the shoulder blade. The other reported
symptoms were fatigue, yellowing of the skin, loss of appetite,
and swollen ankles (Chen, et al., 2020). Laparoscopic
examination of the liver suggested that focal hepatocellular
necrosis was present. Additionally, Nodular regeneration and
distortion of hepatic texture were also observed. Macronodules
with a size of 5 mm were also observed. Moreover, Ultrasound
indicated the surface nodularity with 88% sensitivity.

ICD 10 Diagnosis
· Liver cirrhosis (K74.60)
· Celiac disease (K90)
· Autoimmune hepatitis (K75.4)
· Hepatocellular carcinoma (155)
· Primary biliary cirrhosis (K74.3)
List of all procedures:
· Band ligation (CPT Code = 46221)
· Transjugular intrahepatic portosystemic shunting (TIPS) (CPT
Code = 37182)
· Splenorenal shunt (CPT Code = 37205)
· Paracentesis (CPT Code = 49082)
· Liver transplantation (CPT Code = 47135)
The progression of liver cirrhosis often results in portal
hypertension that ultimately led to esophageal varices. When
the portal pressure increases from 7 mmHg, variceal bleeding
occurs. Therefore, Variceal band ligation is the primary
procedure to manage the complications. Similarly, TIPS is used
to control variceal bleeding to increase the survival of the
patient. Moreover, the splenorenal shunt is used to limit the
recurrent variceal hemorrhage. When the patient has a
splenorenal shunt, there is significant control of portal
hypertension. In this surgical procedure, the patient is also
given general anesthesia, and the vein from the spleen is
disconnected from the portal vein and re-joined to the renal
vein. However, when all the mentioned procedures become
ineffective, then hepatic transplantation is required to replace
the fibrotic part of the liver with a healthy liver. All the
procedures make use of contrasted enhanced intraoperative
ultrasonography.
Complete list of consults during hospitalization:
· Post-surgical consultation for pain management
· Instructions for TIPS to avoid any complications due to shunt.
· The physician consult for antibiotic to prevent infection from
ascites
· Pharma consults for drug treatment

· Ascites drainage
· Vasoactive therapy
· Dietitian consults for diet modification or low salt diet
· Self-care plan provided nursing education plan.
Patient's condition at discharge:
Liver cirrhosis is a serious medical condition that is associated
with certain common complications. The purpose of
hospitalization is to reduce the gravity of the symptoms and
pertinent complications. The patient is likely to discharge when
portal hypertension is curbed by beta-blockers. The variceal
bleeding is controlled and managed by band ligation surgery.
The patient is negative for further ascites by diuretics therapy.
Additionally, the patient has no pain in the upper gastric
quadrant as portal hypertension is controlled. The patient is
exhibiting full compliance with the diet plan and takes food
with low sodium intake. However, the patient is further
compliant with the liver-friendly diet, such as vegetables and
fruits. The blood test shows a relatively low level of liver
enzymes, bilirubin, normal protein levels, and the absence of
bacterial infections (De Munck, et al., 2020). The patient has
done his vaccines for flu, and pneumonia.
Complete physical exam at discharge
Subjective
The nursing staff reported the physical appearance of the
patient. They mentioned that there was no sign of stress or
discomfort. The patient behaved normally. The patient was quite
energetic for his discharge. He was actively taking part in the
discharge procedure. Additionally, the patient was confident
that he would be comfortable with his family and decided not to
go to any nursing care center. The family members of the
patients were rather concerned. They wanted to give him
complete nursing care at home. The medical team was also
agreed to the suggestion of home care of the patient.

Objective
Temp: 36.7 C; BP: 115/78; HR: 80; RR; O2 Saturation: 99%;
Pulse: 90bpm
Physical Examination
General appearance
Normal appearance with no signs of anxiety and stress.
HEENT
PERRLA, no cervical LAD, no thyromegaly, normal tympanic
membrane, oral mucosa normal, no throat infection, normal
nasal passage.
Cardiovascular
No chest pains, no edema, no palpitations
Respiratory
No wheezing, clubbing, no chest discomfort, normal breathing
Gastrointestinal
No abdominal pain, no bloating, no digestive problems.
Genitourinary
Musculoskeletal
The normal range of motion, no muscular abnormalities, normal
body posture.
Integumentary
No bruise, no physical injury.
Extremities
No cyanosis, no clubbing.
Neurological
No dizziness, no vertigo.
Psychiatric
No signs of stress, anxiety, and depression. Normal mood.
What diagnostic criteria confirmed the discharge diagnosis?
The diagnostic criteria for liver cirrhosis involve the absence of
a set of symptoms such as pain in the upper abdominal region
just beneath the ribs and swelling and tenderness.
Complete list of discharge medications:
· Nadolol 40 mg BD
· Tenofovir 25 mg BD

· Lasix, 20 mg OD
· Neomycin 500 mg BD
Pending test results for follow up
1. Alanine transaminase (ALT) (CPT code = 84460)
Reference range = 4 IU/L to 43 IU/L
2. Alkaline phosphatase (ALP) (CPT code = 001107)
Reference range = 44IU/L to 147 IU/L
3. Aspartate Aminotransferase (AST) (CPT code = 001123)
Reference range = 7 IU/L to 38 IU/L
4. Sodium blood test (CPT Code=001198)
Reference range 135mEq/L to 145 mEq/L
5. Serum Albumin test (CPT Code= 82040)
Reference range = 3.8 g/dl to 5.1 g/dl
6. Serum Bilirubin test (CPT Code= 82248)
Reference range = 0.2 mg/dl to 1 mg/dl
7. CT scan (CPT Code= 74176)
8. Elastography (CPT Code= 76981)
Complete list of any pathology
· Edema (R 60.9)
· Portal hypertension (K 76.6)
· Ascites (R 18.8)
· Bacteremia (R 78.81)
Who is responsible for follow-up on final results?
The results of the test that has been ordered are directly related
to the patient and some extent to the providers. The results
require the active involvement of the patient. Therefore,
patients are more responsible for the final results.
Complete list of discharge instructions:
· Cessation of alcohol
· Diet modification with cut back on salt
· Limit canned and fast foods
· High protein intake
· Weight management
· Medication as directed by the physicians
· Avoid aspirin or blood-thinning drugs.

· Vaccinations regarding liver disease
· Slow walking
· Try to reduce stress.
· Avoid having constipation
· Antibiotics for bacteremia
· Sufficient rest and exercise (Muley, et al., 2020)
Complete list of discharge follow-ups
· Lab test for likely blood infections
· Blood test for liver cancer
· Ultrasound and CT scan of the liver every six months
· Endoscopy for varices
· Evaluation of band ligation
· Refer to hepatologist if gastrointestinal bleeding occurs
· Minimum one-month follow-up appointments.
What were the diagnostic criteria needed after discharge?
· Bruising or bleeding
· Fluid buildup in the belly
· Edema in extremities
· Jaundice
· Blood in vomit
· Pain and variceal bleeding
· Disturbance in shunt
· Black stools
· Breathing problems and fatigue
Summary
What questions were raised during the hospital stay?
1.How effectively hospital care reduces the symptoms of liver
cirrhosis and improve the liver function
The patient with liver cirrhosis should avoid alcohol; in this
way, they can limit the onset of alcohol-induced liver cirrhosis.
Moreover, the surgical intervention during hospital stay
controls the complications of portal hypertension.
2.What are the protocols that limit the chance of readmission?
Patient compliance with the medication and active participation
in follow-up guidelines limit the probability of readmission.
What questions were raised that required further exploration?

1. What are the prophylaxis therapies for liver cirrhosis?
2. What is the Prognosis of Band ligation and splenorenal
shunt?
3. What is the life expectancy of the patient with liver
transplantation?
What kind of discharge planning did you need?
My discharge plan must include:
· Information about family care and nursing care
· Nursing education plan
· A simple and comprehensive discharge plan
· Complete information about diet modification and physical
exercise
· Detailed information about medication and the importance of
compliance
· Detail instruction about the regular follow-ups
Characterize your patient interaction activities.
· Effective communication with the patient
· Rapport
· Empathy
· Collaboration
· Technology
· Nonverbal communication
· Open-ended questions
· Probing questions
Overall assessment
Identify health promotions
Health promotion activities enable people to control their health
issues and determinants to improve their health. Liver cirrhosis
health promotion includes healthy eating habits, healthy liver
practices such as cessation of alcohol abuse.
Health education
This is an educational practice that educates people about
health. Liver cirrhosis health education includes diet
modification, limited salt intake, and an increase in protein diet.
These are the set of ethics applied during the treatment of a

patient that gives him autonomy, informed consent, voluntary
participation, and confidentiality, and power of decision-making
regarding certain medical interventions.
Geriatric patients require extra medical care and need multiple
health care providers. It focuses on the health care of geriatric
patients to improve health, prevent disease progression, and
assist the disabilities in older patients.
Expected outcomes.
The outcomes are related to the provided considerations as the
health care system involves many stages of treatment and a
group of people. All these parameters affect the expected
outcomes of the treatment.
References
Chen, K., Sng, W. K., Quah, J. H. M., Liu, J., Chong, B. Y.,
Lee, H. K., ... & Bee, Y. M. (2020). Clinical spectrum of
nonalcoholic fatty liver disease in patients with diabetes
mellitus. Plos one, 15(8), e0236977.
De Munck, T. J., Xu, P., Verwijs, H. J., Masclee, A. A.,
Jonkers, D., Verbeek, J., & Koek, G. H. (2020). Intestinal
permeability in human nonalcoholic fatty liver disease: A
systematic review and meta‐ analysis. Liver
International, 40(12), 2906-2916.
Muley, M., Vespasiani-Gentilucci, U., De Vincentis, A.,
Santonico, M., Pennazza, G., Sanguedolce, S., ... & Antonelli-
Incalzi, R. (2020). Voltammetric analysis for distinguishing
portal hypertension-related from malignancy-related ascites: A
proof of concept study. Plos one, 15(5), e0233350.
Academic clinical discharge summary notes provide a unique
opportunity to practice and demonstrate advanced practice
documentation skills, to develop and demonstrate critical

thinking and clinical reasoning skills, and to practice
identifying acute and chronic problems and formulating a
evidence-based plans of care.
Develop an academic clinical discharge summary note based on
a hospital patient seen during clinical. The discharge summary
note should include the following: ( Acute Care Hospital)
1. Reason for admission: Include the reason for admission, a list
of diagnoses in order of acuity, and an ICD-10 diagnosis.
2. List of all procedures: Include all dates, significant findings,
and any anesthetics and contrast used during procedures.
3. Complete list of consults during hospitalization: Include any
providers or services consulted during stay.
4. Patient's condition at discharge: Include a physical exam
prior to discharge that documents that patient is stable at
discharge and has safe disposition and transportation. What
diagnostic criteria confirmed the discharge diagnosis?
5. Complete list of discharge medications: Full list with all
dosages, frequencies, and quantity of medications prescribed or
dispensed.
6. Pending test results for follow up: Complete list of any
pathology, cultures, radiology, or other diagnostic tests still
pending, and who is responsible for follow-up on final results.
7. Complete list of discharge instructions: Full list of directions
regarding infection prevention, new medications, and returning
to daily activities.
8. Complete list of discharge follow-ups: Full list of any
therapies, treatments, referrals, consults, and follow-up
appointments. What diagnostic criteria were needed after
discharge?
9. Summary: What questions were raised during the hospital
stay? Include all explanations and answers to these questions.
What questions were raised that required further exploration?
What kind of discharge planning did you need? Characterize
your patient interaction activities.
10. Overall assessment: Identify health promotions, health
education, ethical considerations, geriatric considerations, and

expected outcomes.
Incorporate 3-5 peer-reviewed articles in the assessment or
plan. (Minimum 1000 words).
Don’t Forget to include all coding including ICD-10, CPT and
all others.
While APA style is not required for the body of this assignment,
solid academic writing is expected, and documentation of
sources should be presented using APA formatting guidelines,
which can be found in the APA Style Guide, located in the
Student Success Center.
This assignment uses a rubric. Please review the rubric prior to
beginning the assignment to become familiar with the
expectations for successful completion.
Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsANP-650ANP-650-XO0103XBAcademic
Clinical SOAP Note65.0CriteriaPercentage Excellent
(100.00%)Content70.0%Primary or Working Diagnosis10.0%A
one-sentence description of the primary working diagnosis,
pending differential diagnoses, and context or service in which
the patient is being seen is provided and includes supporting
details.Brief Clinical Course10.0%A one-to-two paragraph
description of the current illness or hospital stay, including
pertinent diagnostic findings or procedures and the number of
days since the patient has been hospitalized, is complete with
supporting documentation.Review Of Systems10.0%Five
systems affected by the working diagnosis, along with two
positive or negative effects of the diagnosis on each system, are
provided with thorough details and support.Exam10.0%Five
systems examined within the last 24 hours, including two
positive or negative findings relevant to each system and a full
set of vital signs, are provided with thorough details and
support.Diagnostics10.0%Admission diagnostics are provided
with thorough details and support.Impression or
Assessment10.0%Identification of all acute and chronic

diagnoses in order of ICD-10 priority and any differential
diagnoses being eliminated are provided with thorough details
and support.Plan5.0%A treatment plan that corresponds with the
diagnosis and includes admission type, diagnostics, medications
and dosages, and any consults or follow-up procedures needed
is provided with thorough details and support.Geriatric Specific
Care5.0%A discussion of ethical, legal, or geriatric
considerations is provided with thorough details and
support.Organization and Effectiveness10.0%Mechanics of
Writing (includes spelling, punctuation, grammar, language
use)10.0%Writer is clearly in command of standard, written,
academic English.Format20.0%Paper Format (Use of
appropriate style for the major and assignment)10.0%All format
elements are correct.Documentation of Sources (citations,
footnotes, references, bibliography, etc., as appropriate to
assignment and style)10.0%Sources are completely and
correctly documented, as appropriate to assignment and style,
and format is free of error.Total Weightage100%
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Muhammad Aftkhar
Grand Canyon University
January 25th, 2021
Subjective

Chief complaint
A 62 years old male was brought to the ED by his wife with a
three-day history of short breathing, wheezing, grunting, nose
flaring, productive cough, and gradual change in the color of
sputum from yellow to brown (Fermont et al., 2020).
Primary working diagnosis
· COPD acute exacerbation (J44.1)
Acute exacerbation of chronic obstructive pulmonary disease
manifests a sudden worsening of coughing symptoms, wheezing,
fatigue, color, quantity, and sputum consistency. These
symptoms typically last for several days and cause extreme
discomfort to the patient.
Pending differential diagnosis
· Asthma (J 45.901)
· Congestive heart failure (150.20)
· Pneumothorax (J 93.9)
· Pleural effusion (J 90)
· Pulmonary embolism (126.99)
· Cardiac arrhythmia (149.9)
History of present illness
The patient has been experiencing short breathing for the last
two years, and it has been getting worse for the past four days.
The patient is positive for dyspnea on exertion. The patient has
reported fever, chills, night sweats, chest pain, and palpitation.
Moreover, the patient has signs of lower extremity edema.
However, the patient was rather uncomfortable because of
labored breathing. He has been using different kinds of inhalers,
yet he has not completely recovered from the cough. He has
been hospitalized multiple times for acute COPD exacerbatio ns.
The diagnosis is made based on present medical history,
breathing profile, and spirometry results. FEV1/FVC ratio was
0.68 (68%). The ABG test indicated that the oxygen saturation
is not satisfactory, the values are, PaO2 = 58, PaCO2 = 30,
Arterial blood PH = 7.32, SaO2 = 86. The patient has a long
history of smoking, and he is a chain smoker. He is not an
alcoholic and does not use any illicit drugs. He needs urgent

hospitalization for oxygen therapy.
Past medical history
· Hypertension (I10)
Past surgeries
· Hernia repair surgery (K 46.9)
· 2-day hospitalization
· Multiple hospitalizations for COPD
Family history
· Mother died of heart failure
· Father had COPD
· Brother has hypertension
· Sister is normal
Medication
· Lisinopril 20 mg BD
· Atorvastatin 20 mg BD
· Salmeterol 250/50 inhaler, two puffs daily
· Albuterol nebulizer every 8 hours daily
Hypertension
· Lotensin 40 mg OD
· Zestril 20 mg OD
Emphysema
· Duakril inhaler two puffs daily
Review of systems
Constitutional symptoms
Fatigue, 20 LB weight loss. Slight weakness, no fever, no night
sweats.
The patient seemed fatigued, and he stated that he lost 20 LB
weight during the last six months. However, the patient had no
fever, and no sweating was observed.
Eyes
No obvious visual changes.
The color of the sclera was normal. Upon investigation, the
patient said that he did not feel any visual problem. The
diagnosis has no negative effect on ocular microvasculature.
Retinal oxygen level is normal.

ENT
No epistaxis, no sinus pain, no odynophagia.
The patient denied any sort of nasal bleeding and sinus pain.
The negative impact includes slight voice change sore throat
due to persistent cough.
Cardiovascular
No edema, no palpitations, no chest pain.
The COPD exacerbation negatively impacts the heart rate. The
heart rate increased slightly after some physical activity and the
patient felt breathing problems.
Respiratory
Cough, sputum, wheezing, short breathing, exercise intolerance.
The patient indicated his major complaint as the presence of
crucial symptoms such as persistent wheezing, change in color,
and consistency of sputum.
Gastrointestinal
No abdominal pain, no indigestion, no bloating, slight nausea
due to productive cough.
The patient indicated that he felt bloated right after a meal. The
patient said that he felt slight nausea after coughing.
Genitourinary
No obvious genitourinary problems were observed. The patient
mentioned that he had not any kind of difficulty in passing
urine. Moreover, he did not indicate the presence of polyuria.
Musculoskeletal
No muscle pain, however, a slight decrease in the range of
motion.
As the patient is 62 years old, he has slight disorientation and
limited body motion. However, he did not indicate muscular
pain. There is slight joint pain due to aging.
Integumentary
Cyanosis present on extremities.
Upon examination, there was slight cyanosis on the tips of
fingers. Moreover, the color of the lips was also slightly blue.
Neurological

No headache, no seizures, no faints.
There were no neurological problems reported by the patient.
The patient did not indicate blackout, headache, spasms, and
convulsions.
Psychiatric
Slight anxiety due to breathing problems.
The patient presented no psychiatric problems. However, the
patient was slightly nervous and uneasy due to breathing
problems.
Objective
Vital signs
Temperature: 98.56, Heart Rate: 78, Blood Pressure:110/82,
Respiratory Rate: 10, Weight, 58 kg, Height: 5ft 5 inches.
Physical examination
General
Slight weight loss due to stress-induced by labored breathing.
· Positives: anxiety, disturbed sleep pattern
· Negatives: confusion, fainting
The physical examination shows slight weight loss, pale skin,
and cyanosis on the fingers. However, no lumps and bruises
were present.
HEENT
No headache, normal sclera, intact oral mucosa, intact ear canal.
· Positives: sinus problem, nasal obstruction
· Negatives: eye pain, double vision
The head is atraumatic and normocephalic. Extraocular motility
and alignment are normal. Slightly swollen neck arteries. There
is no gingival bleeding. No oropharyngeal abnormalities were
present.
Respiratory
Cough, wheezing,
· Negatives: hemoptysis, dry cough
The shape of the chest was slightly barreled. The wheezing and
paradoxical abdominal movement was present. Moreover, there

was an increased expiratory time.
Cardiovascular
No palpitations,
· Negatives: chest pain, oedema.
The patient was intolerant to physical exercise and breathing
sound rather diminished. At the beginning of inspiration, coarse
crackles were heard.
Gastrointestinal
No abdominal pain.
· Positives: nausea, loss of appetite
· Negatives: hematemesis, hematochezia
The belly was slightly swollen due to bloating and constipation.
Integumentary
· Positives: cyanosis, dry skin
· Negatives: pruritus, eczema
The skin was slightly dry, and there was cyanosis on the fingers
and lips.
Extremities
· Positives: Slight clubbing, cyanosis
· Negatives: edema
Slight clubbing of fingers was present. Additionally, the patient
said that he had cyanosis for the past three months.
Neurological
Normal body posture and no headache.
· Positives: anxiety, sleep patterns
· Negatives: fainting, special senses
The patient was active and conscious. However, he was slightly
nervous due to breathing problems.
Lab investigations
1.ABG (82803)
PaO2 = 58, PaCO2 = 30, Arterial blood PH = 7.32, SaO2 = 86.
2.COPD assessment test (96417)
CAT score: 30
3.Sputum examination (87077)
o Yellow to brown color sputum

o Increased growth of Gram-negative and Moraxella
catarrhalis
4.WBC (005025)
o 14000 cells/microliter
5.HB (85018)
14.1
6.Hematocrit (85014)
o 47 %
Imaging diagnostic tests
1.Spirometry (94010)
o FVC: 2.28 L
o FEV1: 1.56 L
o FEV1/FVC: 0.68
2.Chest X-Ray (71020)
o Dark pulmonary field
o The flattened diaphragm on the lateral view
o Increased air in the retrosternal area
o AP diameter increased
o Bullae present on both lungs
3.Ct scan (74178)
o Centrilobular emphysema
o Thick bronchial wall
o Small airway obstruction in both lungs
o Slightly narrow trachea at the coronal plane
o Pulmonary hypertension
Assessment
Acute diagnosis
Bronchiectasis (J 47.9)
This is an obstructive lung disorder that is often associated with
a genetic cause. Bronchiectasis can occur alone or with COPD.
However, the major difference is the age as Bronchiectasis
occurs in early childhood.
Congestive heart failure (150.20)
The symptoms are related to COPD such as cough, wheezing,
fatigue, and weakness. Short breathing is also a major symptom
of congestive heart failure; therefore, it is often associated with

COPD.
Tuberculosis (15.7)
TB is a highly contagious lung disorder with pertinent
symptoms of weight loss, fatigue, persistent productive cough,
short breathing. All these symptoms are closely related to
COPD.
Chronic diagnosis
Asthma (J 45.901)
Asthma is one of the most common differential diagnosis of
COPD. Both diseases have more or less the same symptoms.
Long-term asthma results in COPD at later ages. Therefore, I
prioritize asthma on my list of differential diagnoses.
Chronic bronchitis (J 42)
The disease's etiology is different from COPD; however, the
symptoms are more or less the same. These include short
breathing, wheezing with thick and increased mucus production.
Emphysema (J 43.9)
One of the major risk factors of COPD is emphysema. It is
caused by long-term smoking or smoking from a very early age.
The disease affects the alveolar sacs and damages them causing
a severe type of cough and prolonged degeneration of the
tissues (Ono et al., 2020).
Differential diagnosis eliminated
· Bronchiectasis (J 47.9)
· Chronic bronchitis (J 42)
Plan component
A treatment plan that corresponds with the diagnosis.
COPD needs effective treatment and management based on
individualized assessment. Pharmacotherapy would be
influential in reducing the symptoms and frequency of
exacerbation.
Provide information on admission type
The patient must be admitted to a healthcare facility to receive
medication therapy based on certain bronchodilators to curb the
symptoms.

Types of diagnostics
All the pertinent diagnosis is performed, such as AGB, CAT, to
assess airway obstruction severity.
Prescribed medications and dosages
Medication therapy
· Vibramycin 100 mg BD
· Levaquin 500 mg OD
· Long-acting bronchodilators beta2 agonist are preferred
because the severity of obstruction is high (Gold C)
· Inhaled corticosteroid is the other treatment option for a
patient with a severe form of COPD. The ICS also manages
frequent exacerbation.
· Phosphodiesterase 4 inhibitors are also used in patients with
COPD exacerbation with a long history of emphysema or
chronic bronchitis.
· Individualized treatment is used in COPD exacerbation that is
based on GOLD guidelines. Certain antibiotics are also added to
secure treatment goals.
Oxygen therapy
· Long term oxygen therapy is used for COPD, and when the
patient experiences severe hypoxia to improve his life
expectancy, sleep, cognitive and physical performance.
· Pulmonary rehabilitation
· Noninvasive ventilation (Nunez et al., 2020)
Relevant consults or follow-up procedures needed
· Smoking cessation
· Assessment of symptoms control
· Reassessment of inhaler using technique
· Assessing the time for the need for referral
· Spirometry assessments
· ABG assessment
Ethical considerations are the principal ethics that allow the
patient to make his decisions, autonomy, beneficence, and Non-
Malfeasance
legal considerations

The healthcare system's legal consideration includes advance
directives, confidentiality, and informed consent regarding his
treatment.
The geriatric patients are particularly more vulnerable to the
adverse implications of the COPD acute exacerbation. COPD is
generally a very common disorder in older patients; therefore,
geriatric considerations are crucial in this context. Similarly,
there is a high mortality and morbidity rate in older patients,
and they cannot follow routine medical treatment. Appropriate
care must be provided, including regular medication, proper use
of an inhaler, nebulizers, physical exercise, and moral support.
References
Fermont, J. M., Bolton, C. E., Fisk, M., Mohan, D., Macnee,
W., Cockcroft, J. R., ... & Wilkinson, I. B. (2020). Risk
assessment for hospital admission in patients with COPD; a
multi-centre UK prospective observational study. PloS one,
15(2), e0228940.
Nuñez, A., & Miravitlles, M. (2020). Preventing readmissi ons
of COPD patients: more prospective studies are needed.
Ono, M., Kobayashi, S., Hanagama, M., Ishida, M., Sato, H.,
Makiguchi, T., & Yanai, M. (2020). Japanese patients' clinical
characteristics with chronic obstructive pulmonary disease
(COPD) with comorbid interstitial lung abnormalities: A cross-
sectional study. PloS one, 15(11), e0239764.

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