Question

1. A 29-year old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month

• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list Pertinent positive and negative information, Differential and working diagnosis, treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

Questions to ask: Do you have any chest pain with breathing? If so, what is the pain like, when does it occur, and what relieves it? Do you have a cough? If yes, what does the cough sound like, when does it occur, do you bring up any phlegm (sputum) when you cough, what does the phlegm look like?

Physical examination and tests :

• Check the rate of respiration.
• Look for abnormalities in the shape of the patient's chest.
• Ask about the shortness of breath and watch for signs of labored breathing.
• Check the patient's pulse and blood pressure.
• Assess oxygen saturation.
• Check the rate of respiration.
• Look for abnormalities in the shape of the patient's chest.
• Ask about the shortness of breath and watch for signs of labored breathing.
• Check the patient's pulse and blood pressure.
• Assess oxygen saturation.

Also physical exam, taking a patient history and family health history and using different tests. For instance, pulmonary function tests, also known as lung function tests, are frequently used to assess lung function in people with asthma. These tests include spirometry and a test known as methacholine challenge. Spirometry is a simple breathing test. It measures how much air you can blow in and out of your lungs, and how fast and how easily you can do this. A methacholine challenge test may be performed to help establish a diagnosis of asthma. In some cases, the doctor may take an X-ray to see the structures inside your chest, including the heart, lungs, and bones. A chest X-ray is a good test to diagnose pneumonia. It can't, though, identify most breathing problems by itself. For some people with breathing problems, a CT scan of the chest is needed. This scan looks for any problems in the lungs. A CT scan uses X-rays and a computer to create detailed images. If you suffer with chronic sinusitis, your doctor may order a special sinus CT scan. This scan will be used to evaluate your sinuses. Once the problem is diagnosed, your doctor may prescribe effective treatment to help resolve the breathing difficulty.

SOAP Format

Subjective component

Chief Complaint (CC):Complains of weakness, shortness of breath, cough and night sweats for the past month

History of Present Illness (HPI):

The physician will take a history of present illness, or HPI, of the CC.^[1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present.^[10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded.^[1] All information pertaining to subjective information is communicated to the healthcare provider by the patient or his/her representative.^[2]

The mnemonic below refers to the information a physician should elicit before referring to the patient's "old charts" or "old carts".^[1][2][11]

• Onset
  • "When did the CC begin?"
• Location
  • "Where is the CC located?"
• Duration
  • "How long has the CC been going for?"
• CHaracter
  • "Can you describe the CC you're experiencing?"
• Alleviating/Aggravating factors
  • "What makes the CC better and worse?"
• Radiation
  • "Does the CC move or stay in one spot?"
• Temporal pattern
  • "Is there a particular time of day when the CC is better or worse?"
• Severity
  • "On a scale of 1 to 10 (10 being the worst pain you've experienced), how would you rate the CC?"

History:Pertinent medical history, surgical history (with year and surgeon if possible), family history, and social history is recorded.

Objective component: Physical examination of the respiratory tract along with many tests is done to support the assumption of any respiratory tract disorder. To charaterize the level of discomfort and the lab and diagnostic tests already completed.

Assessment component:A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of the patient's problem. It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. This will include etiology and risk factors, assessments of the need for therapy, current therapy, and therapy options. When used in a problem-oriented medical record (POMR), relevant problem numbers or headings are included as subheadings in the assessment.

Plan component: treatments to help relieve your symptoms, such as decongestants and nasal sprays. You can also buy cough medicines and throat lozenges, although there's little evidence to show they help. Some treatments contain paracetamol and ibuprofen.

The patient is told to avoid any frozen foods that would make the condition more worse. A weekly followup is asked to see the progress after then plan componenet.