A SOAP Note on Bronchitis Coursework

Objective Information

Vital Signs: BP 115/75, HR 85, RR 17, Temp 96.2 (oral), SPO2 96% RA.

Height: 5ft 8inch, Weight: 143 lb., BMI: 21.7.

Recent Labs: EKG, January 2019, normal.

General Survey: This is a well-developed, well-nourished African American female that appears younger than the stated age. Her speech is clear, and her answers are congruent with questions. The woman is dressed neatly and appropriately for today’s weather. The patient is calm, and she does not appear to be in distress.

Physical Exam

LUNGS: Resonant throughout. Clear to auscultation bilaterally. Fremitus equal bilaterally. Breath sounds vesicular.

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THORAX: Symmetrical with even expansion, no bony deformities, AP diameter is not increased, there is no tenderness. No supra/infra, axillary, or lymphadenopathy.

HEART: No lifts, heaves, or thrills. PMI 5th LICS at MCL, Regular S1, S2, no S3 or S4. No murmurs rub gallops or clicks.

CHEST: Diaphragm appears lower and flatter.

ABDOMEN: Symmetrical, flat with no lesions, scars, herniations, or abnormal pulsations. The abdomen is soft, with normoactive bowel sounds in all four quadrants. There are no bruises or hums.

LIVER: Is palpable.

BACK: Normal curvature, positive bilateral costovertebral angle (CVA) tenderness.

HEENT: Head normocephalic; eyes clear, no difficulty focusing; ears clean; no pain in the neck; throat clear.

Assessment

Diagnosis: The primary diagnosis is acute bronchitis (ICD-10: J20.9) (“2019 ICD-10-CM Diagnosis Code J20.9,” 2018).

Rationale

Based on symptoms such as prolonged severe cough, chest discomfort, mucus, and fatigue, it seems most relevant to diagnose the patient with bronchitis (Kinkade & Long, 2016). The patient has a family history of heart and lung disease, which necessitates thorough attention to the presented symptoms and allows presuming this diagnosis. Diaphragm appearing lower and flatter is another sign of bronchitis. The liver is palpable, which means that it could have been displaced due to overinflation. Since the patient’s husband is a heavy smoker, she is at an increased risk of developing bronchitis. It is necessary to perform a lung function test and make an X-ray. Also, it is important to order some blood tests and check mucus to exclude the illnesses caused by bacteria.

Differential Diagnoses

Pneumonia due to Mycoplasma pneumoniae

A possible differential diagnosis for the patient is pneumonia (ICD-10: J15.7) (“2019 ICD-10-CM Diagnosis Code J15.7,” 2018).

Rationale

The patient presents such symptoms referring to pneumonia as respiratory problems and occasional fever. However, patients with pneumonia typically have a much higher fever than those with acute bronchitis. Also, pneumonia is associated with bacterial causes whereas acute bronchitis is not (Musher, Abers, & Bartlett, 2017). Therefore, to confirm or reject this diagnosis, it is necessary to perform lab tests to rule out the bacterial origin of the patient’s cough. Since a greatly increased importance of respiratory viruses is one of the major trends in determining pneumonia’s agents, it is crucial to check the patient for viruses (Musher et al., 2017).

Asthma

Another possible diagnosis for the patient is asthma (ICD-10: J45) (“2019 ICD-10-CM Diagnosis Code J45,” 2018).

Rationale

As well as bronchitis, asthma affects the person’s lower respiratory tract. This disease is characterized by occasional or frequent symptoms of cough, dyspnea, and wheezing (McCracken, Veeranki, Ameredes, & Calhoun, 2017). Also, asthma is often associated with allergies, which the patient denies. Clinical and family histories allow concluding that the patient is more likely to have acute bronchitis than asthma. Furthermore, the major difference between acute bronchitis and asthma is the chronicity of bronchospasm. Since bronchospasm is not frequent in the patient and since she has no wheezing or dyspnea, it is relevant to consider asthma only as a differential diagnosis.

Chronic obstructive pulmonary disease

The third differential diagnosis is COPD (ICD-10: J44.9) (“2019 ICD-10-CM Diagnosis Code J44.9,” 2018).

Rationale

COPD is similar to bronchitis and asthma in that it also involves lower respiratory tract infections and may lead to lung function decline (Barnes, 2016). COPD is gene