The following case study is provided in a SOAP
format – it is a way to gather all the data from lab, radiology, interview, and
physical assessment to provide a logical framework to focus on the patient’s
problem and come up with suggested treatment plan.
SOAP stands for: subjective data; what the patient
tells you (how they perceive their chief complaint). Objective data is anything
we can see, feel or measure. Assessment in this regard means putting all the
data together to suggest what is wrong and plan is the treatment based on our
A patient with a long standing history of COPD with
a 60 pack/year smoking history is admitted to the ER with worsening of his
pulmonary condition. He complains of increasing shortness of breath x 3 days
and a congested non-productive cough. The patient has been treated for sleep
apnea at home with a CPAP machine but is not compliant with the therapy.
Subjective: Increasing dyspnea, congestion
Objective: Patient is using accessory muscle of
respiration and has a prolonged expiration time. Upon inspection the patient’s
chest has an increased A-P diameter. Jugular veins distended and skin is moist
and clammy. Pulse is irregular and rapid, lips and nails show cyanosis, the
patient is purse lip breathing. Pitting edema of the ankles is noted.
Further examination reveals the following:
â€¢ Chest auscultation reveals decreased air entry in
the bases with course expiratory crackles noted.
â€¢ Heart sounds show an exaggerated P2
â€¢ Chest percussion – bilateral hyper-resonance
â€¢ CXR – hyper inflated lungs and flattened
diaphragms with consolidation noted in the right lower and middle lobes
â€¢ Vital signs: Temperature 37.4 C. f = 14 with
prolonged exhalation time, HR 88, BP 148/88, Pulse oximetry 76% on room air
â€¢ Labs: Hemoglobin 20 g/dl, Hematocrit 60%, white
blood cell count 22,000, with neutrophils and monocytes elevated. Electrolytes
â€¢ Sensorium – the patient is alert and anxious
Assessment: Exacerbation of COPD (emphysema) with
cor pulmonale and possible pneumonia
Plan: Start oxygen therapy and titrate to a pulse
oximetry reading of 88 – 90%, get culture and sensitivity of sputum to identify
infective microorganism in pulmonary system for antibiotics, suggest a diuretic
such as Lasix or Bumex for the pitting edema and consider pulmonary hygiene to
help patient expectorate secretions. Follow up with ABG one hour after starting
oxygen (they may also get the ABG immediately before oxygen).
In your own words, provide detailed responses to
the following questions:
Provide detailed responses to the following
Why does this patient with COPD have a prolonged
Define the term cyanosis and indicate specifically
what tells you about the patient’s medical status.
What is the common term used for an increased A-P
diameter of the chest and how is it caused?
What is “pursed lip breathing” Why is the
patient doing it? How is it helping the patient?
In this patient, what is causing pitting edema of the ankles?
Explain why, while evaluating the breath sounds,
you would not hear the air well in the bases of an emphysema patient with an
increased A-P diameter.
What does a loud P2 (the second sound you hear in
“lub – dub”) indicate?
Why is the patient’s hemoglobin level so high? What
is this condition called?
Finding course expiratory crackles lung sounds,
what does this tell you about the patient’s lung status? (if you don’t know
read the primer on lung auscultation).
What does a bilateral (on both sides)
hyper-resonant percussion note tell you about the patient’s lungs?
Explain the reason for the increased WBC count –
what would you suggest next?
Submit your answers in at least 500 words on a Word
document. You must cite at least three references in APA format to defend and
support your position.