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I-Human Case Week #3 (Shortness Of Breath)
Complete SOAP Note & Follow-Up Note
Updated
SOAP Note – Shortness of Breath Case
Patient Information
Age: 67 years Sex: Female Height: 5'6" (168 cm) Weight: 174 lb (79.1 kg) Location: Emergency Department Chief Complaint: Shortness of breath
S – Subjective
Chief Complaint (CC)
“I have been having trouble breathing.”
History of Present Illness (HPI)
67-year-old female presents to the emergency department with progressive shortness of breath over the past several days. The patient reports worsening dyspnea, especially with exertion. She states that breathing feels difficult when lying flat and she needs multiple pillows to sleep comfortably. She also reports fatigue and mild chest tightness but denies severe chest pain. Symptoms are aggravated by activity and relieved somewhat by sitting upright. She denies recent trauma but reports a history of respiratory problems. Associated symptoms may include: Cough Fatigue Possible wheezing Orthopnea
Reduced exercise tolerance Denies: Fever Hemoptysis Severe chest pain Recent travel Leg swelling (unless suspected CHF)
Past Medical History (PMH)
Possible relevant conditions: Hypertension Chronic obstructive pulmonary disease (COPD) Heart disease Hyperlipidemia
Past Surgical History
No major recent surgeries reported.
Medications
Common medications for similar patients: Lisinopril Albuterol inhaler Atorvastatin Aspirin
Allergies
No known drug allergies (NKDA)
O – Objective
Vital Signs
(Example typical ER findings — adjust if your case provides numbers) BP: 148/88 mmHg HR: 104 bpm RR: 24 breaths/min Temp: 98.6°F (37°C) SpO :₂ 90–92% on room air
Physical Examination
General Elderly female in mild respiratory distress Appears fatigued HEENT No cyanosis Mucous membranes moist Neck Possible jugular venous distention if CHF suspected Respiratory Tachypnea Possible wheezing or crackles Decreased breath sounds bilaterally Cardiovascular Tachycardia Regular rhythm Possible S3 if heart failure Abdomen Soft, non-tender
Extremities Possible mild edema Neurological Alert and oriented ×
Diagnostic Tests
Possible tests ordered in ED: Chest X-ray ECG CBC BMP BNP Troponin ABG D-dimer (if PE suspected) Pulse oximetry Possible imaging findings: Pulmonary congestion Hyperinflation (COPD) Cardiomegaly
A – Assessment
Primary Diagnosis
Acute Dyspnea
Possible Differential Diagnoses
- Congestive Heart Failure (CHF) exacerbation
- COPD exacerbation
- Pneumonia
- Pulmonary embolism
- Acute coronary syndrome
BNP
ABG
Monitoring
Continuous pulse oximetry Repeat vitals Monitor respiratory status
Patient Education
Smoking cessation Medication adherence Recognizing worsening symptoms
Disposition
Admit if respiratory distress persists Possible telemetry monitoring Follow-up with cardiology or pulmonology
Follow-Up SOAP Note
Patient: 67-Year-Old Female
Visit Type: Emergency Department Follow-Up / Inpatient Reassessment
Diagnosis: Acute Decompensated Congestive Heart Failure
S – Subjective
Chief Complaint “I'm breathing better now but still feel a little short of breath when moving.” History of Present Illness (Follow-Up) The patient is a 67-year-old female previously admitted for shortness of breath suspected to be related to acute congestive heart failure exacerbation. After treatment with oxygen therapy, diuretics, and monitoring , the patient reports improvement in breathing compared to the time of admission. She reports: Breathing is easier while resting Mild shortness of breath with exertion Reduced chest tightness Less fatigue than previously The patient denies: Chest pain Severe dyspnea at rest Fever Cough with sputum Dizziness Palpitations She states she was able to sleep last night with only one pillow instead of three , suggesting improvement in orthopnea. Medication Compliance Patient reports taking medications administered during hospitalization without adverse effects. Review of Systems
General
Patient alert and comfortable at rest. No acute distress.
HEENT
Normocephalic Mucous membranes moist No cyanosis
Neck
Mild jugular venous distention improving
Respiratory
Breath sounds improved Mild crackles at lung bases No severe respiratory distress
Cardiovascular
Regular rhythm Normal heart sounds No new murmurs
Abdomen
Soft Non-tender Normal bowel sounds
Extremities
Mild bilateral lower extremity edema improving
Peripheral pulses intact
Neurological
Alert and oriented × No focal deficits
Diagnostic Follow-Up Results
Chest X-ray
Improvement in pulmonary congestion No new infiltrates
Laboratory
Results CBC
WBC: Normal Hemoglobin: Normal BMP Electrolyt es stable BNP Elevated but trending downward Troponin Negative
A – Assessment
Primary Diagnosis
Acute Decompensated Congestive Heart Failure – Improving
Adjust medications based on fluid status and blood pressure. Monitoring Daily weights Strict intake and output Repeat electrolytes Monitor respiratory status Repeat BNP if necessary Patient Education Discuss with patient: Low sodium diet Fluid restriction if prescribed Importance of medication adherence Monitoring weight daily Recognizing early signs of fluid overload Symptoms to report: Rapid weight gain Increased swelling Worsening shortness of breath Chest pain Discharge Planning If improvement continues: Possible discharge within 24–48 hours. Follow-up appointments recommended: Primary care provider within 1 week Cardiology follow-up Heart failure management education
Follow-Up Instructions
Patient instructed to: Take medications as prescribed Maintain low sodium diet Monitor daily weight Seek medical attention if symptoms worsen
