Soap 1

S - 62-year-old man
- Foundry worker in a steel manufacturing plant for 35
years, who has retired 2 years ago.
- Heavy smoker although he stopped smoking 2 years ago.
- Known case of COPD with multiple hospital admission.
- Admitted because of severe worsening dyspnea.

O - Febrile, cyanotic, and in obvious respiratory distress.

- Appeared malnourished at 6ft tall and weighed 66kg.
- His vital signs:
BP: 154/110.
HR: 95 bpm.
RR: 25 breath/min.
Oral temperature: 38.3 C.
- He was using accessory muscle of inspiration and
breathing through pursed lips.
- An easily visible increase in anteroposterior diameter of
the chest.
- Percussion revealed that he had low-lying, poorly mobile
diaphragm.
- Expiration was prolonged, and his breath sounds were
diminished. No wheezes were note, but crackles could be
heard over the right lower lope.
- CXR showed hyperinflation, severe apical pleural scarring,
a large bulla in the right middle lope, and the right lower
lope infiltrate consistent with pneumonia.
- He has small amount of yellow sputum.
- His ABGs/ PH 7.59, PaCO2 40 mm hg, HCO3- 37 mEq/L,
and PaO2 38 mm hg.
A - COPD.
- Acute right lower lope pneumonia.

P - 2L/min Oxygen by nasal canula.

- IV methylprednisolone.
 Soap 2
S - Patient feels increase chest tightness and worsening SOB.
- Cough with thick sputum.

O - His vital signs:

BP: 160/112.
HR: 97 bpm.
RR: 15 breath/min. shallow
Oral temperature: 37.8 C.
SPO2: 68%.
- Dull percussion notes were elected over the right lower
lope.
- His breath sounds were diminished bilaterally, and
crackles no longer could be heard over the right lower
lope.
- His ABGs/ PH 7.28, PaCO2 82 mm hg, HCO3- 36 mEq/L,
and PaO2 41 mm hg.
- CXR showed more extensive pulmonary infiltrates,
particularly in the right lower chest.

A - Same A1 and worsening pneumonia.

P - Increase oxygen by nasal canula up to 4L/min

- IV methylprednisolone
- Subcutaneous terbutaline every 8 hours.
- Should give antibiotic for pneumonia.