EBC SOAP NOTE

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CLINICAL INTERVENTION 2

 

Evidence-Based Clinical Intervention

NSG6440 Practicum IV: Family Health

 

Evidence-Based Clinical Intervention

Acute Bronchitis

Acute Bronchitis affects patients of all ages and is common complaint in the outpatient setting (Goolsby & Grubbs, 2015). It is often a self-limiting inflammation of the trachea and bronchi due to a viral infection of the upper airway that is characterized by a cough that last one to three weeks, without the presence of pneumonia (Kinkade, 2016).

Typical Presenting Signs and Symptoms

Patients that present with Bronchitis have a complaint of cough that has lasted more than five days and may also have associated sputum production during the acute phase of the illness. Patients may also report associated symptoms of fever, malaise, chest discomfort, chills, and headache (Goolsby & Grubbs, 2015). The complaints of chest discomfort and chills will be mild compared to these same symptoms seen in pneumonia (Goolsby & Grubbs, 2015). Wheezes or rhonchi may be heard when the lungs are auscultated but will clear when patient coughs (Goolsby & Grubbs, 2015). This is no egophony and fremitus will be equal (Goolsby & Grubbs, 2015). Patients may report chest wall tenderness related to cough causing muscle strain (Buttaro et al., 2013).

It is important to for the provider to distinguish acute bronchitis from chronic bronchitis, which is often a condition found in patients with chronic obstructive pulmonary disease that has a cough that last for at least three months in two successive years (Kinkade, 2016).

Pathophysiology of the Problem

Edematous changes to the mucous membrane of the tracheobronchial tree, cell damage to the epithelial, proinflammatory mediators releasing, and having an increase of secretions results in acute bronchitis. Obstruction of the airway may occur causing a transient airway and bronchial hyperresponsiveness. Smoking cigarettes and chemical irritants can increase the severity of the viral infection causing worsening of symptoms (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).

 

Differential Diagnoses

Influenza (J11.1))

Influenza symptoms abruptly appear after an incubation period of 1 to 2 days. Fever, chills, headache, malaise, myalgia, and loss of appetite are symptoms commonly seen. Respiratory symptoms can also appear with influenza which can include a dry cough, nasal congestion, clear nasal drainage, and sore throat. Fever will often rapidly increase between 100o F to 104o F within 12 hours of onset of symptoms. The fever will usually start to decline by the second or third day but has the potential to last four to eight days. Once the febrile stage has passed the patient will have a convalescent phase for about 2 weeks after, which includes a cough and feelings of malaise and fatigue (Buttaro et al., 2013).

Acute Nasopharyngitis (J00)

Patients will complain of feelings of malaise and fever with initial onset but will otherwise feel well except for complaints of nasal congestion. Symptoms resolve by days 5 to 7. Physical exam findings will be negative for fever, sinus pain/tenderness, or chest congestion (Goolsby & Grubbs, 2015).

Pneumonia (J18.9)

Common clinical symptoms of pneumonia are cough, fever, pleuritic chest pain, chills, dyspnea, and sputum production. When mucopurulent sputum is seen it is most often associated with a bacterial pneumonia, whereas a scant and watery sputum appearance is more suggestive of an atypical pathogen. Other features commonly seen in are gastrointestinal symptoms (such as, nausea, vomiting, diarrhea) and mental status changes. Chest x-ray can confirm suspicion for pneumonia (Cash & Glass, 2014).

Evidence-Based Practice Treatment

Proper diagnosing of acute bronchitis is done by performing a detailed history and physical exam that focuses on ruling out pneumonia as the primary diagnosis. Providers need to pay attention to complaints of symptoms that are systematic, such as fever, myalgia, and dyspnea. In acute bronchitis lungs sounds auscultated should be without signs of lung consolidation, such as crackles, egophony, increased fremitus, and/or dullness to percussion. If there is an absence of signs and symptoms patients do not need diagnostic testing completed (Hart, 2014).

The mainstay treatment for acute bronchitis is symptom management and supportive care. This includes over-the-counter (OTC) medications for treatment of the patient’s cough, such as Mucinex DM. Nasal saline spray will help nasal congestions symptoms. Ibuprofen or acetaminophen can be given per directions on packing to relieve fever symptoms. In a randomized control trial ibuprofen was shown to have no benefit compared with a placebo in relieving cough or congestion symptoms for patients with acute bronchitis. Antihistamines, such as Claritin 10mg oral daily, can be used in combination with decongestants to treat the patients acute cough but are not recommended by the U.S. Food and Drug Administration due to warnings for adverse effects with no benefit found when compared to placebo in relieving acute cough symptoms (Kinkade, 2016).

Multiple studies have been completed on antibiotic use in acute bronchitis and have found no improvement in symptoms when patients are prescribed antibiotics. Patients who smoke have been shown to have a significant reduction in their cough with antibiotic treatment by 0.6 days. Due to this knowledge antibiotics can play a minor role with the management of acute bronchitis in these patients (Hart, 2014).

Expected Outcomes

Patients with acute bronchitis are expected to have positive outcomes. It is important that they receive realistic education on the expectation of the duration for their cough that could last up to 3 weeks. Patients can use OTC medications for symptoms control and should be educated to rest, increase their fluids, and use a clean air humidifier for moist air to assist with symptoms. Avoidance of irritants, such as air pollution and smoke will help to decrease symptoms (Buttaro et al., 2013).

Algorithm for Acute Bronchitis

Algorithms are used in the clinical setting for delivery of treatment that is safer and more effective. It is important to appropriately manage initial treatment strategies to prevent complications that could have a negative effect on the patient’s quality of life (Hongo et al., 2017). According to Kinkade (2016) a good algorithm for acute bronchitis is the following:

Family Health Soap Note

Name (Initials): B.B. Date: 11/21/2021
  Age: 20 Sex: Female
 

SUBJECTIVE Data

 
Chief Complaint (CC):

“I’m coughing and I am having congestion for the last week.”
History of Present Illness (HPI): 

Patient is a 20-year-old female that presents to the clinic for complaints dry cough and nasal congestion for the last 6 days. Patient stated coughing is worse when first waking up in the morning but seems the same throughout the rest of the day and night. Patient denies any complaints of fever, chills, or headache. Patient reports she works at grocery store as a cashier and has had several sick contacts coughing around her. Patient denies anyone in the home with the same symptoms.
Medications: (Name of the medication, route, dosage, and reason for med

None

Medication Intolerances:

None
Past Medical History (PMH)

Allergies (Drugs, Food, and Environmental): 

NKDA.

Tobacco, alcohol, or illicit drug use in the past:

Denies smoking.

Denies alcohol use.

Denies drug or substance abuse.

Chronic Illnesses/Major traumas:

Denies any chronic illness or major traumas.

History of any illness:

Childhood: Negative for anything acute-per admits to normal childhood coughs/colds

Adult: None

Genital/Urinary: None

Psychiatric: Denies any psychiatric history.

Hospitalizations/Surgeries:

None
Family History

Father: Alive age 52-Healthy

Mother: Alive age 48-Healthy

Siblings: 1 Sister -Healthy, 1 Brother -Healthy
Social History

Currently works as a cashier part time ,Single and lives in home with parents and siblings. Patient stated she participates in track every year and softball. Patient stated she enjoys spending time with friends at the beach for relaxation.
ROS
General: No fever, chills, night sweats, non-purposeful weight changes or extreme fatigue. Cardiovascular: No chest pain, palpitations, no orthopnea, no edema to lower legs.
Skin: No abnormality identified. Appears well hydrated for age, skin color within normal, pink warm and dry. Respiratory: Positive for non-productive cough. No shortness of breath, hemoptysis, or wheezing.
Eyes: No lenses, no other visual changes reported Gastrointestinal: No abdominal pain, epigastric pain, no nausea, no vomiting, no diarrhea, no black tarry stools, no flank pain.
Ears: No hearing loss, no ringing in ears, no discharge or drainage Genitourinary: Denies urgency, frequency, burning, or change in urine color. Not sexually active, denies any history of STD’s.
Nose/Mouth/Throat: Positive for nasal congestion. No sinus drainage, no throat pain Musculoskeletal: No joint swelling, no gait disturbances, no back pain, no other weakness to extremities.
Breast: No mass, no bumps, no nipple discharge. Neurological: No syncope, no dizziness, no seizures, no weakness, no paresthesias or black out spells
Heme/Lymph/Endo: No bruising, no blood transfusion history, no night sweats, no swollen glands, no increase thirst Psychiatric: No personal history of anxiety and depression. No sleeping difficulties, no suicidal ideation/attempts.
 

OBJECTIVE Data

 
Weight 135 lbs BMI 21.8 Temp 98.8 oral BP 124/70
Height 5 ft 6 inch Pulse 78 Resp 18 O2: 100% RA
General Appearance

Healthy adult, appears stated age in no acute distress. Independent 20-year-old who is very pleasant. Alert and oriented to person, place, time, and situation. Answering questions without hesitation and appropriately. Appears well kempt and clean.
Skin

Pink, warm, and dry. Intact, no lesions or masses. No bruising noted on bilateral arms, wrists, hands, or lower extremities.
HEENT

Head: Appears normal for size and shape, hair evenly distributed. Eyes: Pupils are equal, round and reactive to light, normal conjunctiva. Ears: EACs patent and non-erythematous bilaterally. No mastoid/tragus tenderness. TM’s dull grey bilaterally. No excess cerumen is identified. Nose: No erythema, septum midline, no sinus tenderness, no nasal drainage. Neck: No palpable nodes. Oral mucosa: pink and moist. Teeth: Good dentition. Pharynx: No redness, no exudate or vesicles observed.
Cardiovascular

Regular rate and rhythm, S1, S2 heard on auscultation, no rubs, clicks, murmurs, or extra sounds identified. No thrills, heaves, or lifts with palpitation. Capillary refill less than 2 seconds, pulses bilateral radials 2+, bilateral dorsal pedis 2+. No carotid bruits heard. No edema.
Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds clear throughout all lung fields. Chest wall in non-tender. Respirations are non-labored.
Gastrointestinal

Flat, soft, and non-distended. Normal bowel sounds. Non-tender, no suprapubic tenderness, no bladder distention. No rebound tenderness. No masses or hepatosplenomegaly. Spleen and kidneys are non-palpable. No CVA tenderness.
Breast

Deferred at time of exam.
Genitourinary

Deferred at time of exam.
Musculoskeletal

Full ROM seen in all four extremities. Radial pulses 2+ bilaterally. No tenderness of the bilateral elbows, or shoulders. No crepitus. Normal gait.
Neurological

Speech is clear, good tone, no difficulty swallowing or articulating words. Balance stable with a normal gait. Mental status AAOx3. Reflexes intact 2+. Symmetrical strength in upper and lower extremities. Sensation to light touch and pinprick intact bilateral side of body.
Psychiatric

Alert and oriented to person, place, time, and situation. Clothes are clean. Maintains good eye contact, speech is soft, thoughts organized and clear. Normal rate and cadence when speaking.
Lab Tests

Influenza swab-Negative
Special Tests

None
 

Differential Diagnoses and Diagnosis

 
Primary diagnosis

Bronchitis (J20.9)

This diagnosis is supported by complaints non-productive cough for longer than 5 days,

complaints of nasal congestion, physical exam findings of clear lung sounds, and

negative influenza swab. Patients that present with Bronchitis have a complaint of cough

that has lasted more than five days and may also have associated sputum production

during the acute phase of the illness. Patients may also report associated symptoms of

fever, malaise, chest discomfort, chills, and headache (Goolsby & Grubbs, 2015).

 

Differential diagnosis

Influenza (J11.1)

This is a differential diagnosis that is supported by the patient complaints of cough and congestion for one week and increase of influenza cases throughout Influenza symptoms abruptly appear after an incubation period of 1 to 2 days. Fever, chills, headache, malaise, myalgia, and loss of appetite are symptoms commonly seen. Respiratory symptoms can also appear with influenza which can include a dry cough, nasal congestion, clear nasal drainage, and sore throat. Fever will often rapidly increase between 100o F to 104o F within 12 hours of onset of symptoms. The fever will usually start to decline by the second or third day but has the potential to last four to eight days. Once the febrile stage has passed the patient will have a convalescent phase for about 2 weeks after, which includes a cough and feelings of malaise and fatigue (Buttaro et al., 2013).

 

Acute nasopharyngitis (J00)

This is a differential diagnosis due to patient complaints of cough with nasal congestion, physical exam findings of clear lungs, and negative influenza. Patients will complain of feelings of malaise and fever with initial onset but will otherwise feel well except for complaints of nasal congestion. Symptoms resolve by days 5 to 7. Physical exam findings will be negative for fever, sinus pain/tenderness, or chest congestion (Goolsby & Grubbs, 2015).

 

Pneumonia (J18.9)

This is a differential diagnosis due to patient complaints cough and congestion. Common clinical symptoms of pneumonia are cough, fever, pleuritic chest pain, chills, dyspnea, and sputum production. When mucopurulent sputum is seen it is most often associated with a bacterial pneumonia, whereas a scant and watery sputum appearance is more suggestive of an atypical pathogen. Other features commonly seen in are gastrointestinal symptoms (such as, nausea, vomiting, diarrhea) and mental status changes. Chest x-ray can confirm suspicion for pneumonia (Cash & Glass, 2014).

Final Diagnosis:

Bronchitis (J20.9)- This is the final diagnosis to negative influenza findings, cough occurring for 7 days with nasal congestion, several public sick contacts and no fever, chest congestion, or abnormal lung sounds (Kinkade, 2016).

 

PLAN including education

Plan: Prescription for Benzonatate 100mg PO TID as needed for cough. Antitussive agents can be used when the patients cough is causing a significant discomfort to suppress the protective mechanism the body has for airway clearance (Hart, 2014). Flonase, nasal inhalation, 2 sprays BID for nasal congestion (Cash & Glass, 2014). Tylenol or Motrin (OTC) for fever above 101.0o F to reduce fever discomfort (Cash & Glass, 2014)

 

· Laboratory tests ordered-None.

· Diagnostic tests ordered-None.

· Patient education included: Avoid exposure to sick contacts with possible respiratory illnesses. Stay away from secondhand smoke and don’t smoke or go to areas that are smoke filled. Cover mouth and nose when coughing or sneezing to prevent spread of germs. Use good hand washing methods with soap and water. Use disposable tissues when blowing nose and throw them away right after use. Get a influenza vaccination yearly (Cash & Glass, 2014).

· Non-medication treatments-Rest, increase fluids, and use moist air humidifier for symptoms management (Cash & Glass, 2014).

· Follow-up with patient in 48 hours if symptoms not improving (Cash & Glass, 2014).

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