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SOAP Note 2
Jullissa Thais Fernández Cordero
Escuela de Salud Hima San Pablo
NUC6050 Residency
Dr. Amaro
February 28, 2025
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SOAP Note 2
Biographical Data
Patient initials or account number: 1004436785
Gender / Race / Age: female / Hispanic Latino / 75 y/o
Marital Status: Divorced
Insurance: Reforma
Informant & Reliability: Daughter (reliable)
S (Subjective):
- Chief complaint: “I came home from work, and she barely responded to me, she was
lying on the couch”
- History of present illness (HPI): 75-year-old female with hx of DM2 and HTN with no
known allergies who was brought to the ER because of altered mental status 1 day ago.
She was admitted to the ICU because of septic shock secondary to pneumonia. Currently,
on vasopressors for hemodynamic support and mechanical ventilation due to respiratory
failure. Patient sedated and on MV; unable to provide subjective information, so her
daughter provides the information by telephone.
- Past medical history (PMH): DM2, HTN
- Surgical history: none
- Current home medications: metformin 500 mg BID, losartan 100 mg daily
- Allergies: NKDA
- Family History: HTN, Alzheimer
- Social history: Smoker
- Inpatient diet: NPO
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- Gyn: G-2 P-2 A-0 C-0
- Review of systems (ROS): Gen: + fever, Eyes: -, ENT: -, Resp: + cough, + SOB, CV: -,
GI: -, Neuro: + hypoactive, Psych: -, GU/GYN: + increase urinary frequency, Skin: -,
Musc: -
O (objective):
- Vital signs:
BP: 90/50 | HR: 120 | RR: 22 | Temp: 102 °F | O2 sat: 95% | Pain: 3/10 | Weight: 185 lbs.
| Height: 63”
- Physical findings:
o Constitutional: patient appears critically ill, sedated and intubated
o HEENT: normocephalic and atraumatic. PERRL, normal eyes inspection, dry oral
mucosa, no JVD, no vascular bruits on the neck, ETT in-place
o Neurologic: sedated, non-responsive to verbal commands
o Chest: normal anteroposterior diameter, good expansion and symmetrical
movement.
o Heart: tachycardic and rhythm, normal S1 and S2, no rubs, gallops, or murmurs.
o Lungs: bilateral crackles heard on auscultation; decreased breath sounds in lower
lung fields
o Abdomen and pelvis: soft, non-tender, not distended, normal bowel sounds in all
4 quadrants, no organomegaly, no pulsatile masses.
o Musculoskeletal: vertebral spine well align, FROM.
o Extremities: weak peripheral pulses, FROM, capillary refill >3 seconds
o Skin: hot to the touch, dry and with poor turgor, no rashes, lesions, or bruising
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- Pertinent laboratories:
100 23
XXX 133
11.5 220
18.0 150 XXX XXX
34.5 4.0 XXX 1.5
XXX XXX XXX XXX
XXX
XXX XXX XXX XXX
o U/C: pending
o Urinalysis: + nitrites, + WBC, cloudy, loaded with bacteria
o B/C: pending
o ABG’s: pH: 7.30 / PaCO2: 50 / PaO2: 75 / HCO3 23
o Lactate: 4.5mmol/L
- Pertinent diagnostic imaging:
o CXR: Bilateral infiltrates, consistent with pneumonia or pulmonary edema.
- EKG: sinus tachycardia
- Analysis of symptoms and physical findings, pertinent positives and negatives: The
patient is showing clear signs of septic shock, including persistent low blood pressure,
fever, and elevated lactate levels, which suggest poor tissue perfusion. They are also
experiencing respiratory distress, with bilateral crackles and decreased breath sounds,
raising concerns for acute respiratory distress syndrome (ARDS) or pneumonia.
Laboratory tests reveal an elevated white blood cell (WBC) count and increased lactate
levels, further indicating a severe infection and compromised circulation. A chest X-ray
confirms bilateral infiltrates, consistent with pneumonia or ARDS. Also on U/A findings
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consistent with UTI. On a positive note, the patient has no abdominal tenderness, making
an intra-abdominal source of infection less likely, and no neurological deficits,
suggesting the central nervous system is not currently affected.
Septic shock, as defined by the Infectious Diseases Society of America, involves
sepsis with circulatory, cellular, and metabolic dysfunction, often requiring vasopressor
therapy to maintain a mean arterial pressure (MAP) of at least 65 mm Hg. It is also
associated with elevated lactate levels (≥2 mmol/L) despite adequate fluid resuscitation.
The presence of bilateral infiltrates on the chest X-ray and respiratory symptoms aligns
with common pulmonary sources of sepsis, such as pneumonia, which is a leading cause
of ARDS. U/A also remarkable to UTI, which is another common source of sepsis in
older adults. The elevated WBC count and lactate levels provide further evidence of
septic shock and a severe systemic infection.
- Differential diagnosis:
o Septic shock: elevated WBC, elevate lactate and fever with a source of infection
plus hypotension responsive to vasopressors
o Pneumonia: bilateral infiltrates on CXR; potential source of infection
o Urinary tract infection: known source of sepsis, U/A
o Acute kidney injury: possible due to hypotension and sepsis
o Encephalitis: Though the primary source of sepsis is pneumonia, CNS infections
should be ruled out if there is clinical suspicion
o Cardiogenic shock: Acute coronary syndrome (ACS) or an arrhythmic event
could contribute to hypotension, leading to decreased cerebral perfusion.
o Toxic or drug induce cause
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A (Assessment):
o 75-year-old female with septic shock secondary to pneumonia and UTI, currently on
norepinephrine for hemodynamic support and mechanical ventilation for respiratory
failure
- R65.21 Septic shock: patient with a source of infection, increase in WBC,
hypotension despite fluid resuscitation, fever AMS and tachycardia are signs and
symptoms of sepsis with shock; patient with a qSOFA of 3 (high risk for in hospital
mortality)
- J18.9 Pneumonia: patient with CXR positive for pneumonia
- N39.0 Urinary tract infection: increase in urinary urgency and a + urinalysis,
remarkable for UTI
- N17 Acute kidney injury: Possible due to hypotension and sepsis; monitor renal
function closely
- E11.59 Type 2 diabetes mellitus with other circulatory complications
- I10 Essential hypertension
P (Plan):
- Non-pharmacologic
o Hemodynamic monitoring with vital signs every 2 hrs
o Mechanical ventilation with the following settings and parameters
o Intake and output every 8 hrs
o Aspiration precautions: elevate head 45 degrees
o Suction as needed
o Oral care per protocol every 4 hrs
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o Position changes as needed
- Pharmacologic
o Hemodynamic support
§ Norepinephrine 0.1 mcg/kg/min IV infusion, titrate to maintain MAP
≥65 mmHg
o Broad spectrum abx:
§ Piperacillin/tazobactam 4.5 g IV every 6 hrs
o Sedation:
§ Propofol 5 mcg/kg/min IV infusion, titrate to desired effect
o Fluid management:
§ 0.9 nss continuos infusion to run at 80 ml/hr by IV pump infusion
o GI coverage and ulcer prophylaxis:
§ Famotidine 20 mg IV daily
o DVT prophylaxis:
§ Lovenox 30 mg SQ daily
o Glucose management:
§ Humalog before meals per Insulin sliding scale
o Hypoglycemia:
§ D50% if glucose lower than 50 mg/dL PRN
o Fever:
§ Acetaminophen PR 1g for fever every 6 hrs PRN
o Bronchodilators
§ Levalbuterol nebulized every 6 hrs
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- Laboratories
o Sputum cultures
o CBC
o CMP
o Lactate
o Sed rate
o CRP
o PT/PTT/INR
- Consultations
o Pneumology
o Infectious disease
o Nephrology
- Education / patient-family teaching
o Understanding septic shock
o Infection prevention
o Vaccination for pneumonia and COVID-19
- Anticipatory guidance
o Emotional support
o PMR
- Follow-up
o Will follow up on patient status, consultants recommendations and diagnostic
test results once they are available and make appropriate adjustments, unless
an acute change in patient condition or critical value reported.
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References
Coen, D. (2023). Fluids and vasopressors in septic shock: Basic knowledge for a first approach
in the emergency department. Emergency Care Journal, 19(1).
[Link]
Dellinger, R., Levy, M. M., Rhodes, A., Annane, D., Gerlach, H., Opal, S. M., Sevransky, J. E.,
Sprung, C. L., Douglas, I. S., Jaeschke, R., Osborn, T. M., Nunnally, M. E., Townsend, S.
R., Reinhart, K., Kleinpell, R. M., Angus, D. C., Deutschman, C. S., Machado, F. R.,
Rubenfeld, G. D.,...Moreno, R. (2013). Surviving sepsis campaign. Critical Care
Medicine, 41(2), 580–637. [Link]
Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., Suppes, R., Feinstein,
D., Zanotti, S., Taiberg, L., Gurka, D., Kumar, A., & Cheang, M. (2006). Duration of
hypotension before initiation of effective antimicrobial therapy is the critical determinant
of survival in human septic shock*. Critical Care Medicine, 34(6), 1589–1596.
[Link]