NU-664B Week 4 Assignment 1: iHuman Simulation i-Human Soap Note – Bobbie Case Study

NU-664B Week 4 Assignment 1: iHuman Simulation i-Human Soap Note – Bobbie Case Study

Chief complaints (CC): Bobbie is 18 y/o student who presents with sudden onset of myalgias, pleuritic pain, SOB, and productive cough.

HPI: Bobbie had symptoms of the flu about ten days ago. He did not seek medical attention but now presents with the return of symptoms that appear worse. He reports fevers, chills, rigors, muscle aches, tender cervical lymph node, and right-sided chest wall pain aggravated by deep breathing and coughing. His cough is productive of thick yellow mucus, and he feels a bit winded when he climbs up or runs to class.

Assessment

1. Community-Acquired Pneumonia (CAP) (J18.9)
2. Rationale: CAP is pneumonia acquired outside healthcare facilities. However, it is the leading cause of morbidity, mortality, hospitalization, and increased care costs (Shoar & Musher, 2020). The disease is caused by streptococcus pneumoniae (pneumococcus) (Shoar & Musher, 2020). The clinical manifestation of community-acquired pneumonia ranges from mild to severe pneumonia. Pneumonia is characterized by productive cough, respiratory distress, fever, shaking chills, rigor, myalgias, and chest pains. The disease is considered the primary or final diagnosis because Bobbie is a college student living within the college environment. He might have acquired pneumonia after hanging out with friends. Also, the patient presents all the symptoms of community-acquired pneumonia during the hospital visit.
3. Pulmonary embolism (I26)
4. Rationale: pulmonary embolism is an illness caused by a blood clot that develops within the pulmonary artery in the lungs (Poyiadji et al., 2019). The symptoms of the disease relevant to the case study include cough, muscle aches, chest pains, and fever. The clinical manifestations make it possible to include pulmonary embolism as a differential diagnosis (Poyiadji et al., 2019). However, the patient only presents fewer symptoms that can be associated with pulmonary embolism. Symptoms such as chills and rigors are not related to pulmonary embolism. Thus, the disease cannot be considered the primary or final diagnosis.
5. Influenza (J10. 1)
6. Rationale: influenza is an acute respiratory disease caused by the influenza virus (Dolin, 2020). The disease is transmitted from one person to another through droplets made whenever people talk, sneeze, or cough (Dolin, 2020). The clinical manifestation of influenza is rapid onset of headache, myalgia, sore throat, weakness, fever, non-productive cough, and nasal discharge. Influenza risk factors include age (worse for children under two years and adults over 65), pregnancy, obesity, living conditions, and race (Dolin, 2020). The disease is ruled out by the patient’s history. Bobbie had flu over the last ten days and did not receive a vaccination or seek medication. However, most people get the flu once every few years. Thus, the flu could not have reappeared within ten days.
7. Covid-19 (Z20.822)
8. Rationale: Covid-19 is a communicable respiratory disease caused by the coronavirus (Poyiadji et al., 2019). The disease is transmitted from one human to the next through respiratory droplets produced whenever an individual with the virus sneezes or coughs (Poyiadji et al., 2019). The clinical manifestations or symptoms of the disease relevant to the case include cough, sore throat, myalgia, fever, respiratory distress, and nasal discharge. The clinical diagnosis can be considered because Bobbie presented most of the symptoms of upper respiratory infections.