Complex Case Study
Molly Wilkinson
College of Nursing, Walden University
NURS 6540F
Professor Donna Petko
July 25th, 2023
Focused SOAP Note Template
Patient Information:
R.W, 66, M, Caucasian
S.
CC “I feel like I have the flu. My whole body hurts.”
HPI: R.W. is a 66 year old caucasuan male who presents to the office today with body aches described constant and rated 8/10, fever, SOB, and cough. R.W. states his symtoms started two days ago and have progressivety been getting worse over the last 48 hours. He has been alternating Tylenol and ibuprofen with minimal relief. He and his wife went to New York to visit his children and flew home four days ago. His wife currently denies experiencing similar symptoms.
Current Medications: Lisinopril 20MG – 1 Tablet PO Once Daily. Multivitamin – 1 Tablet PO Once Daily.
Allergies: NKDA
PMHx: Essential Hypertension – Diagnosed three years ago. Obesity – BMI 32.
Soc and Substance Hx: R.W. works full time running a print press. He is married to his wife for thirty years and they have two children and two grandchildren. R.W. denies any previous or current tobacco use. Drinks alcohol on occasion (average once a month – beer). They live in a single family home on the water. He denies texting and driving, has working smoke detectors, and wears his seat belt at all times in the car. He appears to have a positive support system in place.
Fam Hx: Father – Died at 86 from Lung CA. Unknown other PMH. Mother – 82. Living. DX. HTN, Hyperlipidemia, amd DM type 2. He has two brothers who are alive and “healthy.” R.W. states he does now know their medical history.
Surgical Hx: Carpal Tunnel Release Right Wrist – 2021
Mental Hx: No PMH of Depression or Anxiety. Denies any thoughts of harming himself or others.
Violence Hx: No concerns related to safety within personal, home or community setting.
Reproductive Hx: N/A
ROS:
GENERAL: Positive for fever, chills, and fatigue.
HEENT: Eyes: Denies any change in vision. Ears, Nose, Throat: Denies any hearing loss. Positive for congestion and runny nose.
SKIN: Denies any noted rash or itching.
CARDIOVASCULAR: Denies any chest pain, pressure or discomfort. Denies any edema.
RESPIRATORY: Positive for SOB and cough. Denies any sputum production.
GASTROINTESTINAL: Denies any N/V/D. Denies abdominal pain or discomfort.
GENITOURINARY: Denies any difficulty with urination.
NEUROLOGICAL: Positve for headache. Denies any numbness or tingling in extremities.
MUSCULOSKELETAL: Positive for body aches. Denies any stiffness.
HEMATOLOGIC: Denies any bleeding or easily bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: Denies any current or past history of anxiety or depression.
ENDOCRINOLOGIC: Denies ay heat intolerance.
O.
Physical exam:
GENERAL: Appears well nourished and in no acute distress.
VITAL SIGNS: BP 128/74, RR 16, O2 98% on RA, HR 72 T 99.8
HEENT: Pupils are round, reactive, and equal to light. Clear drainage from bilateral nares noted. Oral mucosa moist and pink.
Lymph Nodes: Symmetrical – no inflammation noted.
Heart: S1 and S2 Noted. Absense of Murmur. NSR.
Lungs: Bilateral and equal chest rise. Breathing minimally labored with no use of accessory muscles. Lungs are clear to all lobes. No wheezing, rales, or rhonchi noted.
Diagnostic results:
Chest X-Ray – Ordered (Pending Radiology to Read)
Respiratory Panel – + for COVID
CBC: WNL
A.
Differential Diagnoses:
COVID – R.W. presented with body aches, fever, SOB and cough. He states he he recently went to New York with his wife to visit his chidren and grandchildren. His respiratory panel returned postitive for COVID. Some of the more common signs and symptoms of COVID include fever, cough, SOB, and fatigue (Centers for Disease Control and Prevention, 2022).
Influenza – Although Influenza season is typically Fall and Winter, R.W. presented with some of the common S/S associated with infleunza. He denied having received his flu vaccine this past year. He has had generalized body aches along with fever over the last 48 hours. The flu often comes on suddently and is accompanied by fever, cough, runny nose and body aches (Centers for Disease Control and Prevention, 2022).
Pneumoina – Pneumonia is an infection of the lung that can be caused by a virus, bacteria, or fungus. Pneumonia can cause one to have fatigue, fever, and cough (National Heart, Lung, and Blood Institute, 2022). R.W. states he has been experiencing a fever, fatigue, and cough for the last two days.
P.
Diagnostic Plan: XR Chest, CBC, and Viral Panel. Chest X-Ray will be completed to assess for COVID PNA. CBC will be used to assess for signs of infection – in particular reviewing of the WBC and the viral panel was compelted to assist in diagnosing and treating the patient appropriately. R.W was instructed to quarantine for five days and then to wear a mask for the next five days while out in public. He was iinstructedto inform those he was around recently including his wife, children, and grandchildren of his COVID diagnosis as COVID is very contagious. APRN prescribed Tylenol PRN for fever/pain, OTC Mucinex PRN Congestion, Prednisone 20MG 1 tablet PO for five days, and Azithromycin 500MG X 1 day and 250MG X 4 days. He is scheduled for a follow up visit in two weeks with APRN.
Also included in this section is the reflection.
This was a great refresher case as it had been a few months since I had seen a patient in the primary care setting with COVID. In the last week at clinical, we have seen an increased number of those with COVID symptoms. I agree with my preceptors plan but I did question the start of the antibiotic. At the time, we did not have the results of the chest x-ray back and the CBC was normal. R.W. was complaining of SOB with fever which was her reasoning for starting the antiobiotic. She explained that those with COVID who have a fever with SOB and sputum production she often prescribes an antibiotic to cover for potential PNA. I did research the topic and found that antibiotic use in COVID is not standardized and there is no evidence to support the use of them in a routine COVID case (Duenas-Castell et al., 2022). The only thing I may have done differently is hold off on the antibiotic until I had the results of the chest x-ray as she stated they are often given results same day.
References
Centers for Disease Control and Prevention. (2022). Flu Symptoms and Complications. Retrieved from https://www.cdc.gov/flu/symptoms/symptoms.htm
Centers for Disease Control and Prevention. (2022). Symptoms of COVID-19. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
Dueñas-Castell, C., Polanco-Guerra, C. J., Martinez-Ávila, M. C., Almanza Hurtado, A. J., Rodriguez Yanez, T., Gutierrez-Ariza, J. C., & Rico-Fontalvo, J. (2022). When to Use Antibiotics in COVID-19: A Proposal Based on Questions. Cureus, 14(7), e27398. https://doi.org/10.7759/cureus.27398
National Heart, Lung, and Blood Institute. (2022). Pneumonia. Retrieved from https://www.nhlbi.nih.gov/health/pneumonia/symptoms
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