Acute Pneumonia SOAP Note

Date: December 5, 2022

Time: 14:55

Subjective:

Demographics: 62-year-old Caucasian male

CC: The patient is a 62-year-old male, who presents with pneumonia.

HPI: The patient is a 62-year-old male patient who has been admitted for pneumonia. His lungs
are very tight upon admission. He has wheezes bilaterally and rhonchi on the left side mostly. He
appears to be weak and is febrile.

Medications:
Medication Dose Route Frequency Indication
Xanax (Alprazolam) 0.5mg By mouth At bedtime Insomnia
Acetaminophen 325 mg By mouth As needed every 4 Pain
hours
Sodium Chloride 0.9% 1000 ml NA Continuous Dehydration

Allergies: Azithromycin (Arrhythmia), Levofloxacin (Other, unknown)

Objective:

Heart: Occasional Tachycardia, regular rhythm without murmur, gallop or rub.

Lungs: Reveals expiratory wheezing throughout. Significant rhonchi on the left base. He has a
productive cough, and he is coughing copious green purulent sputum.

Skin: Poor skin turgor, warm to touch

Chest X-ray: Reveals a left lower lobe opacity with pleural effusion.

Pain level: 4

Vitals:
Height 68 in
Weight 138 lb (62.7 kg)
BP 118.78 mmHg
Temp 103.1°F (39.5°C)
HR 87 to 115 bpm
SPO2 90-95% on room air

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Labs:
Result Reference Range
Serum Chemistry
Na 138 mEq/L 135-145 mEq/L
K 4.2 mEq/L 3.5-5.0 mEq/L
Cl 105 mEq/L 96-109 mEq/L
CO2 24 mEq/L 23-29 mEq/L
Ca 9.2 mg/dL 8.6-10.2 mg/dL
BUN 41 mg/dL 8-20 mg/dL
SCr 1.7 mg/dL 0.6-1.2 mg/dL
Glucose 112 mg/dL 80-120 mg/dL
CMP
Alkaline Phosphatase 99 IU/L 39-117 IU/L
ALT 24 IU/L 4-40 IU/L
AST 25 IU/L 4-37 IU/L
Bilirubin 0.4 mg/dL 0-1.2 mg/dL
CBC
Hemoglobin (Hgb) 15 g/dL Males: 13.5-16.5 g/dL
Hematocrit (Hct) 43% Males: 41-50%
Platelet count 300,000 100,000-450,000
WBC 21,200 cells/ml 4,000-10,000 cells/ml

 QTc interval: 512 msec

 Serum creatinine: Previous 2 years of labs – 0.8 mg/dL and 0.9 mg/dL
 Additional pertinent labs:
o CrCl: 40.0 ml/min based on Actual Body Weight
o IBW: 68.4 kg
o AdjBW: 62.7 kg

Assessment:
 Problem 1: Acute Pneumonia
o Goal of therapy
 Prevent or treat systemic consequences of infection
 Select a treatment that is patient specific and has low toxicities
 Minimize antimicrobial resistance
 Prevent recurrence of infection
 Eradicate causative pathogen
 2019 ATS Guideline for the Diagnosis and Treatment of Adults with
Community-acquired Pneumonia
o Discussion of subjective and objective information

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 
The patient was admitted to the hospital and diagnosed with acute
pneumonia, likely community acquired due to no history of recent
hospital stay or ventilator use. The patients only home medication is
Xanax (Alprazolam), and his only other past medical history is chronic
insomnia. He currently presents with occasional tachycardia, expiratory
wheezing, and significant rhonchi on the left base. He also has a
productive cough which is producing a copious green purulent sputum.
It also appears as though the patient is dehydrated due to his poor skin
turgor. The patient reports an allergy to azithromycin and levofloxacin,
which should be taken into account when developing his therapy plan.
Based on the patients current labs, his white blood cells are very
elevated as well as his BUN, which is about twice the normal level. It is
also important to note that the patients CrCl is 40 ml/min and may
require dosing adjustments. The factors presented above are indicative
of pneumonia, but based on the criteria, it would be classified as a minor
pneumonia infection, therefore it is important to treat him before it
develops further. The patient is also currently experiencing pain, likely
due to the infection, for which he is taking acetaminophen.
o Treatment Considerations
 Per the 2019 ATS Guideline for the Diagnosis and Treatment of Adults
with Community-acquired Pneumonia, we will want to order sputum
samples from the patient in order to determine the causative agent. In the
meantime, we will treat the patient empirically.
 The patient will be treated empirically until we have a causative agent,
the patient has also stated that he has an allergy to levofloxacin, which is
one of the first-line empiric treatments. Therefore, it would be best to
use Ampicillin/sulbactam, a beta-lactam antibiotic, as the first-line agent
in this patient. This medication must be used in combination with a
macrolide or doxycycline; therefore, we will use Ampicillin/sulbactam
in combination with Doxycycline as the patient also reported an allergy
to a macrolide antibiotic. Both of these medications will not require any
dosing adjustments with the patients current kidney function.
Ampicillin/sulbactam is only available in an IV formulation but the
patient is currently inpatient and will likely stay inpatient for the
remainder of his treatment.
 A second option for this patient would be a different beta-lactam
antibiotic, such as Ceftriaxone, which will also need to be used in
combination with doxycycline. Ceftriaxone tends to have more adverse
effects than the first option, such as hemolytic anemia and
hypersensitivity, making it a good second option.
 A third option for the patient would be Cefotaxime, which is also a beta-
lactam antibiotic, which means it will also need to be combined with
doxycycline. Cefotaxime does require dosing adjustments based on the
patients current kidney function, making this a good third option due to
the complexity of redosing if the function changes.

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  Problem 2: Acute Kidney injury
o Goal of therapy
 Reduce kidney injury and complications due to reduced kidney function.
 Maintain fluid and electrolyte balance.
 Maintain blood pressure.
 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury
o Discussion of subjective and objective information
 The patient’s current labs show that the patient’s serum creatinine has
increased significantly over the past 2 years, starting at a value of 0.8
mg/dL and is currently at 1.7 mg/dL, which would classify him with a
Stage 2 kidney injury, based on the KDIGO guidelines. The patients
creatinine clearance is currently 40 ml/min, meaning he will require
dosing adjustments with certain medications. The patient has also
arrived with signs of dehydration, such as poor skin turgor. This
dehydration can cause further injury to his kidneys and could be the
explanation for his current kidney status.
o Treatment Considerations
 Per the 2012 KDIGO Clinical Practice Guideline for Acute Kidney
Injury, the best option for this patient is to provide supportive care
through managing their blood pressure and fluids, as well as nutritional
support in order to ensure he is hemodynamically stable.
 The first and only treatment option for the patient is IV fluids, which our
patient is already currently receiving. A vasopressor could also be added
to the patients regimen if the response is not enough with IV fluids, but
is not necessary at this time.

 Problem 3: Insomnia
o Goal of therapy
 Correct underlying sleep complaint
 Consolidate sleep
 Improve daytime functioning and sleepiness
 Avoid adverse effects from treatment
 2017 JCSM Clinical Practice Guideline for the Pharmacologic
Treatment of Chronic Insomnia in Adults
o Discussion of subjective and objective information
 The patient presented to the hospital with only one home medication,
Xanax, which is assumed to be used for his chronic insomnia. Xanax or
Alprazolam is a benzodiazepine, which does have a sedating affect, but
isn’t intended for long term use. The patient is not complaining currently
but the medication should be addressed due to its long term affects.
o Treatment Considerations
 Per the 2017 JCSM Clinical Practice Guideline for the Pharmacologic
Treatment of Chronic Insomnia in Adults, the first line for insomnia is
always non-pharmacologic therapy. While the patient is already on a

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 therapy for his insomnia, it is important to ensure that the patient is
attempting non-pharmacologic therapy.
 The first option for this patient would be to discontinue his alprazolam
and try non-pharmacologic therapy in combination with a different
medication while he is inpatient at the hospital. This will ensure the staff
are able to help him implement these non-pharm changes. The first line
treatment for the patient would be a non-benzodiazepine,
benzodiazepine receptor agonist hypnotics, such as Eszopiclone. While
it would be great for this patient to try just non-pharm therapy, I don’t
think the patient will be accepting of this as he was previously on a
medication.
 If this doesn’t work for the patient, we could try another medication in
the same class, such as Zolpidem, which comes in a sublingual tablet
which gives it a faster time to affect, but it also does not help as much
with waking up throughout the night.
 A third option for this patient is Ramelteon, which is a melatonin agonist
and is not a controlled medication. This medication works to regulate the
sleep-wake cycles over time, which could be very effective, but the
patient may not be conducive to this medication as it doesn’t have an
immediate effect.

Plan:

 Problem 1: Acute Pneumonia

o Treatment Options:
 Pharm:
 Start Ampicillin/Sulbactam 3 gm IV every 6 hours for 5 days
 Start Doxycycline 100mg IV every 12 hours for 5 days
 Safety monitoring:
o Serum creatinine, kidney function
 Efficacy monitoring:
o Sputum culture to determine pathogen
o Resolution of clinical symptoms
 Counseling:
o Finish the full course of both medications, even if you are
feeling better.
 Non pharm: Drink lots of fluids
 Follow up: Follow up in 5 days with PCP (if no longer inpatient) to assess
symptoms, if sputum cultures come back before then, reassess medication
therapy to ensure proper coverage.
 Problem 2: Acute Kidney Injury
o Treatment Options:
 Pharm:
 Continue Sodium Chloride 0.9%, 1000ml IV continuously as
needed

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  Safety monitoring:
o Electrolyte levels (Na, K,), Serum creatinine
 Efficacy monitoring:
o Increase in skin turgor
 Counseling:
o Avoid medications that may exacerbate kidney damage,
including over-the-counter medications such as NSAIDs.
 Non pharm: Drink lots of fluids throughout the day and avoid anything
that can contribute to dehydration, such as caffeine.
 Follow up: Monitor daily while inpatient and follow up in 5 days with
PCP to obtain labs.
 Problem 3: Insomnia
o Treatment Options:
 Pharm:
 Start Eszopiclone 1mg once daily before bedtime as needed
 Stop Alprazolam 0.5 mg once daily at bedtime
 Safety monitoring:
o Abnormal thinking, signs of dependence, behaviour
changes
 Efficacy monitoring:
o Resolution of symptoms (insomnia)
 Counseling:
o Take this medication right before you go to bed, do not take
with or right after a meal.
 Non pharm:
 Practice sleep hygiene (no caffeine or alcoholic beverages 4-6
hours before bed, avoid heavy meals before bedtime, minimize
light and noise in the bedroom)
 Follow up: Follow up in 5 days with PCP (if no longer inpatient) to assess
resolution of symptoms

Resources: Treatment Guidelines

 2019 ATS Guideline for the Diagnosis and Treatment of Adults with Community-
acquired Pneumonia
 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury
 2017 JCSM Clinical Practice Guideline for the Pharmacologic Treatment of Chronic
Insomnia in Adults

Writer ID
Emily Seely
Student Pharmacist (Husson University School of Pharmacy)
Phone: 123-456-7890