Questions:
Please answer the following questions in SOAP note format:
-Indicate the primary diagnosis for this patient.
-Include at least one evidence-based journal article that supports your rationale. Indicate if there is a gold Standard for the treatment of the primary diagnosis. If so, make sure to incorporate gold standard strategies into the treatment and management of this patient's primary diagnosis.
-Provide at least two differential diagnoses that specifically relate to the primary diagnosis. Support with at least one evidence based rationale for each differential diagnosis.
-List the routine labs/diagnostics for the primary diagnosis.
-List pharmacological management for the primary diagnosis.
-List non-pharmacologic management strategies for the primary diagnosis.
-For the patient education portion of the treatment plan, specifically address evidence based strategies.
-For smoking cessation as one part of the patient education. Also address the recommended vaccinations that that would be indicated for this patient. Address any other educational needs as necessary.
-Summarize the history and results of the physical exam. Discuss the differential diagnosis and rationale for choosing the primary diagnosis. Include one evidence-based journal article that supports your rationale and include a complete treatment plan that includes medications, possible referrals, patient education, ICD 10 codes, and plan for follow-up.
Background
L.J. is a 65-year-old male who presents to the office with increased shortness of breath that has gotten worse over the last few months. He reports that having shortness of breath is nothing new, but he has recently started to feel shortness of breath when he is performing his daily activities. He denies any fever, contact with any sick individuals or any weight loss. Other than the shortness of breath, he indicates that he has a chronic cough that is occasionally productive of whitish sputum. He has a 65-pack-year history of cigarette smoking. He is in the clinic today because of his concern about his worsening shortness of breath.
PMH
L.J. has a history of hypertension, cataracts, and osteoarthritis
Current Medications
Ibuprofen 600 mg po TID
Lisinopril 20 mg po QD
Hydrochlorthiazide 25 mg po QD
Simvastatin 20 mg po QD
Meloxicam 7.5 mg QD
Surgeries
Left knee arthroplasty in 2013
Allergies: No know allergies
Social History: 65 pack year history of cigarette smoking; denies alcohol intake or illicit drug use; is married and recently
retired
Family history: Father has history of HTN; Mother has history of "mild" stroke; Brother has a history of Hyperlipidemia.
Physical Exam
Vital signs: BP 138/88; HR 88 (regular), RR 18, T 98.8
General appearance: Thin and mildly dyspneic
Lungs: Mild end-expiratory wheezing. Pursed-lip breathing noted and has a prolonged expiratory phase.
Heart: S1 and S2 RRR with distant heart tones. No murmurs
Abdomen: Soft, non-tender with positive bowel sounds. No abdominal bruits
Extremities: Full ROM of all extremities. No edema. All pulses 2+