Discussion answer post
critique the Soap note of the two people who posted before you.. Your critique should identify at least one positive and one area for future growth.
AS
:
CC: Patient states, “I’ve been having shortness of breath, a cough, and I feel exhausted.”
-HPI: A 31-year-old female states she has been having shortness of breath, cough, and fatigue for 5 days. The patient states the cough gets worse when she lays down at night and the shortness of breath increases on exertion. The patient states she has tried to take over-the-counter liquid guaifenesin, but it does not help. The patient states that her mother, whom she helps care for, is positive for Covid-19. The patient states she has not had the Covid-19 vaccination.
-ROS: patient states she feels short of breath on exertion, ongoing cough, fatigue, lethargy, slight weakness periodically, patient denies wheezing, any diarrhea, confusion, no loss of vision, no nausea or vomiting, denies any trouble with urination, no chest pain, no numbness, no dizziness, no loss of appetite, no changes in taste or smell, and patient denies any pain
-Medical History: Hypotension
-Surgical History: Cesarean section x1
-Family History: Mother and maternal grandparents are positive for diabetes, hypertension, and obesity.
-Social History: Denies any drug use and tobacco use, drinks alcohol socially
-Allergies: none
-Medications: Mirena IUD birth control
Objective:
-Physical Exam:
Blood pressure – 109/67
Heart rate – 69
Respiratory rate – 18
Oxygen saturation – 94% on room air
Temperature – 99.8 (Oral)
Weight – 75.9 kg (167 lbs.)
The patient is fully alert and oriented, and answers all questions appropriately, appears fatigued, lung sounds diminished, breathing is even and labored, cough with phlegm present, no pursed lip breathing, no nasal flaring, PERRLA, active range of motion in all extremities, mucosa is pink and moist, abdomen is soft, bowel sounds normal, no diaphoresis noted, no jugular vein distention, no swelling or edema noted.
Abnormal chest X-ray: Ground glass opacities in both mid and lower zones of the lungs.
Differential Diagnosis: Covid-19 virus, community-acquired pneumonia, Influenza
Assessment: Covid-19 virus pneumonia
Plan: Along with the chest x-ray, the patient will need a rapid Covid-19 test and possibly a PCR Covid-19 test. The patient will also need a CBC, CMP, ESR, C-reactive protein (Cascella et al., 2021). According to the NIH guidelines for Covid-19, the patient is exhibiting mild signs and symptoms of Covid-19 (Aleem et al., 2021). The patient was given a prescription for azithromycin PO 500mg x1 day and then 250mg PO daily x4 days. The patient was also given ascorbic acid 500mg PO daily. Patient teaching is highly important with Covid-19 positive patients. The patient was educated on how to monitor her oxygen saturation level and when to call the provider. The patient was educated on the importance of completing the entire antibiotic regimen and the adverse effects to observe for when taking this medication. The patient was educated on the quarantine process, sanitization, and mask-wearing to prevent the spread of the virus to others. The patient should follow-up in two to three weeks when her quarantine process is over.
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