Running head: WEEK 3 SOAP NOTE 1

Week 3 SOAP Note

Student’s Name:

Institutional Affiliation:

WEEK 3 SOAP NOTE 2

Week 3 SOAP Note

Patient Information:

R.J., 67 years, Caucasian, Female.

Subjective

CC (chief complaint): the patient complains of increased shortness of breath and weakness. She

uses accessory muscle and pursed-lip breathing.

HPI: A 67-year-old Caucasian female complains of shortness of breath and weakness. She is

using accessory muscle and pursed-lip breathing. The patient also looks pale. She denies any

cough and has been receiving chemotherapy for left-sided breast cancer

Current Medications

Dexamethasone 4 mg 3 tabs PO bid on days 2 and 3 of cancer tx.

Metoclopramide HCL 10 M.G. 1 tab tid

Aprepitant 80 & 125 mg 1 tab daily one hour before chemo, 80 mg 1 tab on day 2 and 3 in the

AM (Nausea)

Metoprolol Succinate E.R. 50 mg 1 tab in the AM

Hyzaar 100-25mg 1 tab in the AM

Aspirin 81 mg 1 tab in the AM

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Hydralazine HCL 50 mg 1 tab with food bid

Diclofenac Sodium 50 mg 1 tab with food or milk bid prn pain

Hydrochlorothiazide 25 mg 1 tab in AM

Pravastatin Sodium 40 mg 1 tab QHS

Magnesium Oxide 400 mg 1 tab in the AM

Spironolactone 25 mg 1 tab in the AM

Gabapentin 100 mg 2 caps tid

Zofran 2 mg 1 tab daily

Allergies: No known allergies

PMHx: Reports a history of hypertension, hypercholesterolemia, lower extremity edema,

venous insufficiency, osteoarthritis, and left breast cancer. The patient has also undergone a total

hysterectomy.

SocHx: Denies smoking or alcohol use. Lives with adult children and a member of the Baptist

faith. The patient does not perform regular physical exercise because she uses a wheelchair.

Currently not working.

Fam Hx: Both parents are deceased. Mother had a history of breast cancer.

ROS:

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GENERAL: Reports fatigue. No reported weight changes or fever.

HEENT: Eyes: No reported visual complications. Ears, Nose, Throat: No reported hearing loss,

sore throat, sneezing, or congestion.

SKIN: The patient did not report any itching, rashes, or skin complications.

CARDIOVASCULAR: No reported chest pain or discomfort. Edema on the lower extremities.

RESPIRATORY: Shortness of breath and weakness.

GASTROINTESTINAL: No abdominal or bowel complications.

GENITOURINARY: Does not report any changes in urination patterns or genital

complications.

NEUROLOGICAL: Does not report dizziness or headache.

MUSCULOSKELETAL: No reported muscle, joint, or back complications.

HEMATOLOGIC: Reports feeling fatigued and dizzy. No abnormal bleeding.

LYMPHATICS: No enlarged nodes.

PSYCHIATRIC: No reported anxiety or depression.

ALLERGIES: No reported allergies

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Objective

Physical exam:

Vitals:

Blood Pressure: 115/77

Heart Rate: 125

Temperature: 97.9

Respiration: 20

Oxygen Stat: 94%

Height: 5’ 4”

Weight: 120ibs

BMI: 20.6

General: Patient well-groomed, well-nourished, and cooperative with the exam. Appears alert

and fatigued.

Oral Cavity: Mucosa moist, light pink.

Throat: Clear.

Neck/Thyroid: Neck supple, full range of motion, no cervical lymphadenopathy.

Skin: No suspicious lesions, pale, warm, and dry.

Heart: Tachycardia

Lungs: Cleat to auscultation A/P bilaterally.

Abdomen: Flat, normal bowel sounds, soft, and non-tender.

Back: Full range of motion.

Extremities: Bilateral non-pitting edema to lower extremities.

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Neurologic: non-focal.

Psych: Alert, oriented, cooperative with the exam.

Diagnostic Results:

A computed tomography (C.T.) scan was conducted to check for pulmonary embolism

and cancer metastatic to the lungs. A CT scan involves the use of an X-ray to provide detailed

images of internal organs (Wegener, 2015). The CT scan showed that the patient had a

pulmonary embolism, and her breast cancer had spread to the lungs.

A lab test was also performed to test for chemotherapy-related anemia. The first test

involved a complete blood count (CBC). The assessment checks for hemoglobin and hematocrit

levels (McClatchey, 2014). It also counts the number of white blood cells, platelets, and red

blood cells in the blood (McClatchey, 2014). A CBC also measures the size of red blood cells.

The other procedure performed to test for anemia involved a physical exam where I listened to

the patient's heart to evaluate the heartbeat (McClatchey, 2014). The process also included

evaluating the lungs for irregular breathing and feeling the stomach to check for the liver and

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spleen size (McClatchey, 2014). The examinations tested positive for anemia, and the patient

required a blood transfusion.

Assessment

Differential Diagnoses

The patient, in this case, showed symptoms of shortness of breath and non-pitting edema

to the lower extremities. The symptoms may be caused by various conditions, as discussed

below.

Anemia. This is a condition that occurs due to the lack of enough red blood cells to

transport adequate oxygen to the body (Steensma, 2017). The symptoms of anemia include

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fatigue, pale skin, irregular heartbeat, weakness, and shortness of breath (Steensma, 2017). Other

symptoms that may include lightheadedness, and edema on the lower extremities (Steensma,

2017). Although edema is not a common symptom in anemia, it can occur due to insufficient

supply fluid circulation in the body (Steensma, 2017). Causes of anemia include the damage of

red blood cells or the loss of red blood cells (Steensma, 2017). Red blood cells transmit oxygen

from the lungs to other body parts. The damage of red blood cells thus hinders oxygen

transportation which might leading to breathing problems and fatigue (Steensma, 2017).

Pulmonary embolism. Pulmonary embolisms refer to blood clots in the arteries that

transport blood to and from the heart to the lungs (Tapson, 2018). The clots block normal blood

flow and may cause serious health problems such as low oxygen levels in the blood and lung

damage (Tapson, 2018). Pulmonary embolisms may travel to the lungs from a deep vein in the

legs. The clots occur when blood cannot flow freely through the leg (Tapson, 2018). Pulmonary

embolisms may also result from the use of medications such as birth control pills or recent

surgery (Tapson, 2018). The symptoms of the condition include edema, shortness of breath, and

a feeling of dizziness (Tapson, 2018).

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Lung cancer. This is a form of cancer that affects the lungs (Cooley, 2015). Symptoms

include chest pain, shortness of breath, headache, hoarseness, and edema (Cooley, 2015). The

risk factors of lung cancer are smoking or exposure to second-hand smoke and having a family

history of lung cancer (Cooley, 2015). Lung cancer can also occur after another form of cancer

has spread to the lungs (Cooley, 2015).

Heart failure. Heart failure is an illness that transpires when the heart muscle fails to

pump enough blood to the other body parts (Judge, Pawitan, Caldwell, Gersh, Kennedy, &

Participants, 2015). High blood pressure or narrowed arteries in the heart can weaken the heart

muscle making it unable to pump efficiently (Judge et al., 2015). Symptoms include shortness of

breath, fatigue, edema, irregular heartbeat, and chest pain (Judge et al., 2015).

Discussion

For the patient, in this case, the primary diagnosis was anemia. This is because the patient

showed most symptoms of anemia such as fatigue, shortness of breath, tachycardia, and edema

on the lower extremities. The anemia could be as a result of the destruction of red blood cells by

chemotherapy. However, the lab tests conducted showed pulmonary embolism and cancer

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metastatic to the lungs. Therefore, when offering treatment, I will also treat the patient for

pulmonary embolism and lung cancer.

Plan

Medication

Pulmonary embolisms can be fatal, so I will first administer thrombolytic drugs to reduce

the clots. Examples of thrombolytic drugs include urokinase and streptokinase (Tapson, 2018). I

will consult with my preceptor to determine the dosage and the specific drug suitable for the

patient.

Since the patient, in this case, have cancer, it will be challenging to treat her pulmonary

embolisms due to a risk of recurrent embolisms. Therefore, I plan to provide extended

anticoagulation as opposed to the usual three-month therapy offered to patients with no

additional complications.

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The patient also required a blood transfusion because she has anemia. However, she

declined so I will consult my preceptor on other possible interventions.

Alternative Therapies

The patient, in this case, has breast cancer which is spreading to other parts of the body

despite her receiving chemotherapy treatment. Therefore, she might need alternative therapies to

manage to improve her quality of life. Some alternative therapies I would recommend for the

patient include the following.

Exercise. I will create a moderate-intensity exercise plan with the patient which she

should perform regularly. The patient requires moderate levels of activity since she cannot

perform rigorous exercise due to shortness of breath. Gentle exercise will help in decreasing

fatigue and stress. It will also help to improve the quality of sleep, which is essential for

alleviating discomfort (Cassileth & Deng, 2014). When creating an exercise plan for this patient,

I will research on exercises suitable for individuals who use wheelchairs to ensure the exercises

meet her needs.

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Relaxation techniques. The patient will also require relaxation to help her relieve stress. I

will refer the patient to an expert who offers relaxation therapy. Relaxation will help to calm the

patient's mind and muscles, thus improving the quality of life (Cassileth & Deng, 2014).

Health Promotion Strategies

The patient, in this case, has a lifelong condition. Patient and family education is hence,

important in this case.

The patient had earlier rejected a blood transfusion suggestion. In case I will have not

found other ways to manage anemia, I will have to educate the patient on the blood transfusion

procedures and its significance in her treatment. I will also inform the patient of the need to

follow her treatment and the ways in which she can improve her quality of life.

The patient also requires an at-home oxygen therapy. Therefore, I will have to educate

the patient on how to handle an oxygen tank and the precautions to avoid accidents. I will also

inform the family on ways of caring for the patient and how to avoid accidents at home. I will

also discuss with the family the benefits of a healthy diet and regular exercise for the patient.

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Disease Prevention Strategies

The patient, in this case, has anemia resulting from chemotherapy. To prevent severe

complications, I will recommend an iron-rich diet. She also has difficulty breathing, so I will

advise the family members to avoid smoking near her.

Diagnostic Tests

After the initial treatment for pulmonary embolism, I will perform a C.T. scan to determine if

there are any clots left.

Referral

I will refer the patient to the oncology department for cancer treatment.

Follow up interval.

After the initial discharge, I will ask the patient to visit the hospital every week for a check-up.

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Reflection

The task assigned for this week was a bit challenging since this was my first time

conducting a diagnosis in real-life experience. However, I learned a lot from the activities. I first

learned how to collect patient history and perform confirmatory diagnostic tests using the

collected data. I did not know how to perform a C.T. scan, but through the guidance of my

preceptor, I was able to perform the test. I also learned that patients do not always accept the

suggested treatment. Therefore, as a medical practitioner, I should know how to communicate

with patients to win their trust. It was also confusing to diagnose the patient above since she had

multiple conditions. Nevertheless, through the help of my preceptor, I was able to make anemia

and pulmonary embolism diagnosis. From what I have learned, I think I need to conduct a

thorough history collection and physical examination the next time I will be making another

diagnosis.

________________________

Preceptor Signature and Date

Signature is REQUIRED for this assignment.

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References

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Cassileth, B. R., & Deng, G. (2014). Complementary and alternative therapies for cancer. The

oncologist, 9(1), 80-89.

Cooley, M. E. (2015). Symptoms in adults with lung cancer: a systematic research

review. Journal of pain and symptom management, 19(2), 137-153.

Judge, K. W., Pawitan, Y., Caldwell, J., Gersh, B. J., Kennedy, J. W., & Participants, C. A. S. S.

(2015). Congestive heart failure symptoms in patients with preserved left ventricular

systolic function: analysis of the CASS registry. Journal of the American College of

Cardiology, 18(2), 377-382.

McClatchey, K. D. (Ed.). (2014). Clinical laboratory medicine. Lippincott Williams & Wilkins.

Steensma, D. P. (2017). Is the anemia of cancer different from chemotherapy-induced anemia?

Journal of Clinical Oncology, 26(7), 1022-1024.

Tapson, V. F. (2018). Acute pulmonary embolism. New England Journal of Medicine, 358(10),

1037-1052.

Wegener, O. H. (2015). Whole-body computerized tomography.

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