create a SOAP note  with information below

Create – objectives to understand assessment and treatment of COPD

Add 3 APA style sources no older than 5 years

Chief Complaint Pt states gastric acid is getting into his lungs, making it hard to breathe and coughing with flems History of Present Illness 50-year-old male with a past medical history of GERD, COPD presented to ED with complaints of worsening cough and shortness of breath for the last 3 days. Patient reports he started feeling heart burn about 2 months ago and soon after developed a cough that worsened within the last 3 days. Associated with nasal congestion, sore throat, chest pain and yellow mucus that is hard to expectorate. He reported taking Tagamet for acid reflux. Reported allergy to PPIs. Denied history of asthma, sick contact or smoking. Patient stated he had GERD surgery about 20 years ago. Reported being a supervised and doing office work. Patient exercises 4 -5 times a week however he had to stop due to symptoms. Reported exposure to second hand smoke as a child. At time of evaluation patient was sitting on stretcher, alert and oriented. Speaks in short sentences. He is currently on room air, sat 92%. He denies fevers, HA, chest pain, abdominal pain, nausea, vomiting, diarrhea or dysuria. Patient is admitted to telemetry for further management of acute bronchitis. Plan of care was discussed with patient, he verbalized understanding.

VS on arrival to ED: BP 140/83, HR 68, RR 17, O2 sat 92% on room air. Patient afebrile. BMI 34.6.
Labs on admission: CBC remarkable for neutrophils of 70.1%. BMP remarkable for chloride of 109 and creatinine of 1.36. Troponin x1 negative. Lipid panel remarkable for HDL of 69. COVID-19 negative.

EKG shows sinus rhythm with sinus arrhythmia.
Chest x-ray: Hyperinflation no consolidation. Review of Systems Constitutional: No unexplained weight gain or loss, fevers, chills, fatigue
Eye: No recent visual problems
ENMT: No ear pain, nasal congestion, sore throat
Respiratory: + shortness of breath, +cough
Cardiovascular: N+ chest pain, no palpitations, leg edema
Gastrointestinal: No nausea, vomiting, diarrhea,+ heartburn
Genitourinary: No dysuria, hematuria
Hema/Lymph: Negative for bruising tendency, swollen lymph glands
Endocrine: Negative for excessive thirst or urination, heat or cold intolerance
Musculoskeletal: No back pain, joint pain, muscle pain
Integumentary: No rash, itching, abrasions
Neurologic: No history of fainting, memory loss,numbness
Psychiatric: No anxiety, depression
Allergic/Immun: No nasal allergies, itchy/red eyes, enlarged lymph nodes Physical Exam

Vitals & Measurements
T: 36.7 °C (Oral)
HR: 68 (Peripheral)
HR: 99 (Monitored)
RR: 20
BP: 132/98
SpO2: 96%
WT: 67 kg (Measured)
BMI: 26.17 General: Alert, well nourished, speaks in short sentences
Eye: Pupils equal, EOMI, normal conjunctiva, no scleral icterus
ENMT : Normocephalic, normal hearing, moist oral mucosa.
Neck: Supple, non-tender, trachea midline, no JVD
Respiratory : Normal respiratory effort, regular rate, bilateral wheezing to auscultation, O2 sat 92% on RA
Cardiovascular: Regular rate and rhythm, no murmur or pedal edema
Gastrointestinal: Soft, non-tender, non-distended, normal bowel sounds, no rebound or guarding.
Genitourinary: No costovertebral angle tenderness to palpation
Musculoskeletal: MAE, No digital clubbing or cyanosis. Negative Homans sign.
Skin: Skin is warm, no rashes or lesions.
Neurologic: AAOx3, MAE, Sensation to touch intact
Psychiatric: Good judgment and insight, appropriate mood and affect Assessment/Plan

1. Acute bronchitis COPD exacerbation. Patient presented to ED with complaints of worsening cough and shortness of breath for the last 3 days. Patient reports he started feeling heart burn about 2 months ago and soon after developed a cough that worsened within the last 3 days. Associated with nasal congestion, sore throat and yellow mucus that is hard to expectorate. He reported taking Tagamet for acid reflux. Reported allergy to PPIs. Denied history of asthma, sick contact or smoking. Patient stated he had GERD surgery about 20 years ago. Reported being a supervised and doing office work. Patient exercises 4 -5 times a week however he had to stop due to symptoms. Reported exposure to second hand smoke as a child.
-No leukocytosis, patient afebrile.
Chest x-ray: Hyperinflation no consolidation. COVID-19 negative.
plan: Started on Rocephin and Zithromax, respiratory treatments, systemic and inhaled steroids, supplemental oxygen as needed, follow RPP, check mycoplasma, strep pneumonia and Legionella

2. Acute renal injury (N17.9: Acute kidney failure, unspecified) creatinine of 1.36.
plan: IVF, avoid nephrotoxins, adjust medications per creatinine clearance, BMP in a.m.

3. Chest pain (R07.9: Chest pain, unspecified) Denies at this time. Likely atypical. Patient reports chest pain associated with coughing.
Troponin x1 negative. Lipid panel remarkable for HDL of 69.
EKG shows sinus rhythm with sinus arrhythmia.
Chest x-ray: Hyperinflation no consolidation.
Plan: Telemetry, trend troponin, cardiology consult, check A1c, follow echocardiogram

4. GERD (gastroesophageal reflux disease) (K21.9: Gastro-esophageal reflux disease without esophagitis) History of GERD surgery. Reports heart burn. Takes Tagamet.
Plan: Started on Pepcid and sucralfate, GI consulted

VTE prophylaxis: Lovenox
GI prophylaxis: Pepcid

Case and plan of care discussed with admitting physician.

Medical Necessity Needs cardiology and GI evaluation, IVF, IV antibiotics, systemic and inhaled steroids. Pending troponins and echocardiogram. Problem List/Past Medical History Ongoing GERD (gastroesophageal reflux disease) Procedure/Surgical History

· GERD

· Knee

Home Medications Home Medications (3) Active
albuterol 90 mcg/inh inhalation aerosol 1 puffs, PRN, Inhale, Every 6 hrs
Carafate 1 g oral tablet 1 g = 1 tabs, Oral, BID
metoclopramide 5 mg/5 mL oral syrup 5 mg = 5 mL, Oral, BID Allergies Prevacid Social

Inpatient

albuterol 2.5 mg/0.5 mL (0.5%) inhalation solution, 2.5 mg= 0.5 mL, Nebulized Inhalation, Every 2 hrs, PRN

Antivert, 25 mg= 1 tab(s), Oral, Every 6 hrs, PRN

Artificial Tears, 2 drops, Eye-Both, Every 2 hrs, PRN

Ayr Saline 0.65% nasal solution, 1 sprays, Nasal, 6 times per day, PRN

bisacodyl, 10 mg= 1 supp, Rectal, Daily, PRN

budesonide 0.5 mg/2 mL inhalation suspension, 0.5 mg= 2 mL, Inhale, BID

Carafate, 1 g= 1 tab(s), Oral, QID

cefTRIAXone

famotidine, 20 mg= 2 mL, IV Push, BID

guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid, 5 mL, Oral, Every 4 hrs, PRN

ipratropium-albuterol 0.5 mg-2.5 mg/3 mL inhalation solution, 3 mL, Nebulized Inhalation, Every 6 hr

labetalol, 10 mg= 2 mL, IV Push, Every 4 hr, PRN

Lovenox, 40 mg= 0.4 mL, SubCutaneous, Daily

LR 1,000 mL, 1000 mL, IV Continuous

melatonin, 5 mg, Oral, Daily at bedtime, PRN

methylPREDNISolone sodium succinate, 40 mg, IV Push, Every 8 hrs

metoclopramide, 5 mg= 5 mL, Oral, BID before meals

Metoprolol Tartrate, 2.5 mg= 2.5 mL, IV Push, Once, PRN

ondansetron, 4 mg= 2 mL, IV Push, Every 4 hrs, PRN

simethicone, 80 mg= 1 tab(s), Oral, QID, PRN

Tessalon Perles, 100 mg= 1 cap(s), Oral, TID, PRN

Tylenol, 650 mg= 2 tab(s), Oral, Every 6 hrs, PRN

Zithromax IV, 500 mg= 1 tab(s), Oral, Every 24 hr

History

Alcohol

Current user, Occasional Use

Substance Use

Never

Tobacco

Tobacco Use: Never (less than 100 in lifetime). Exposure to Secondhand Smoke: Yes. Family History Arthritis: Mother. MI: Father. Stroke: Father.

Lab Results (Most Recent 36 hrs) Hemoglobin: 15.6 g/dL (09/13/23 08:25:00)
Hematocrit: 45.7 % (09/13/23 08:25:00)
WBC: 10.56 K/uL (09/13/23 08:25:00)
Platelet Count: 237 K/uL (09/13/23 08:25:00)
Sodium on Blood: 141 mmol/L (09/13/23 08:25:00)
Potassium on Blood: 3.6 mmol/L (09/13/23 08:25:00)
Chloride on Blood: 109 mmol/L High (09/13/23 08:25:00)
CO2 on Blood: 26 mmol/L (09/13/23 08:25:00)
Anion Gap: 6 mmol/L (09/13/23 08:25:00)
Glucose on Blood: 96 mg/dL (09/13/23 08:25:00)
Creatinine on Blood: 1.36 mg/dL High (09/13/23 08:25:00)
BUN on Blood: 11 mg/dL (09/13/23 08:25:00)
Calcium (Total): 9.1 mg/dL (09/13/23 08:25:00)
TSH: 1.67 uIU/mL (09/13/23 08:25:00)
Hemoglobin A1C (Glycosylated): 5.5 % (09/13/23 08:25:00)
Cholesterol Level: 186 mg/dL (09/13/23 08:25:00)
Triglycerides: 92 mg/dL (09/13/23 08:25:00)
HDL Cholesterol: 61 mg/dL High (09/13/23 08:25:00)
Cholesterol/HDL Ratio: 3 ratio (09/13/23 08:25:00)
LDL: 107 mg/dL (09/13/23 08:25:00) Diagnostics Results (Last 48 hrs) Chest Single View XR

09/13/23 09:03:00
IMPRESSION:
Hyperinflation no consolidation.
– 039321 – 9/13/2023 9:08
AM