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Posted: September 6th, 2023

Edwin is a 69-year-old male who comes into the clinic today

Case study for Week 6
Remember that this is a mock patient. You will make up the history and exam findings as if you have interviewed this patient and performed an exam. You are required to use a SOAP note template with citations and references in APA format. You will include three ddx with supportive documentation, citations, and references! Please be aware Turnitin similarity should be less than 20%
If the information was not provided in the case study, be creative and ask yourself what would be important for me to ask this patient if he were in my office. What systems should I include in the ROS and for the Exam? Hint: You will always, always have the heart, lungs, HEENT, and abdomen in a patient with these symptoms. What else is important?
Use the following case to complete a focused SOAP note:
Edwin is a 69-year-old male who comes into the clinic today stating that over the past few days, he has had a fever and chills, cough, and has been quite fatigued. He didn’t take his temperature because he did not have a thermometer but he “felt hot.” He says he is coughing up a little phlegm. He states that it hurts when he takes a deep breath. He also states that his appetite has not been very good. He has been taking Tylenol with minimal relief. He has also been drinking tea to try to break up the phlegm.
Edwin is a nonsmoker and non-drinker. He has been very healthy and has no medical problems. He has never had surgery.
On the exam, his vital signs are: BP 130/80; P 84; R 14; T 103.2; Pulse ox: 94%.
The exam reveals decreased rales and rhonchi, more pronounced in the left lower lung fields, with increased fremitus and dullness to percussion. Chest x-ray reveals a consolidation in the left lower lobe. This appears to confirm that he has pneumonia.
At the end of the soap note on a separate page please answer this question.
1. Which bacteria is the leading cause of pneumonia and the one that he most likely has?
2. What is unusual about this pts history as compared to most pts that are at risk for s.pneumoniae?
3. In this type of pneumonia, does the sputum analysis indicate gram positive or negative diplococci? There would also be a large number of _________?
4. What other bacteria must be considered?
5. What is the best way to identify the pathologic agent?
6. Where does the best sputum sample come from?
7. When is the best time to get a sputum sample? Why is that the best time?
8. When sending the sputum to the lab, how does the lab determine it is an adequate sample?
9. Name four other diagnostics that can be done on this patient to further understand his condition.
10. If obtaining blood cultures, how many sets are typically obtained?
11. When choosing an antibiotic to treat this patient, it is important to try to cover for all pathogens, especially gram-negative organisms. True or false?
12. When treating on an outpatient basis, what class of drug should be used for this previously healthy man with no use of antimicrobial therapy within the previous 3 months?
13. Although there have been cases of resistance against this class, it is still recommended for pts without risk. Please write out the Rx directions the way with the med and the sig how you would write it for the pt.
14. The choice of antibiotic therapy depends on three important factors. What are they?
15. In most cases, improvement is seen within __________ to _________ hours of initiation of antibiotics.
16. Should cough medicine be recommended?
17. Name two patient education points you would share with this patient

SOAP Note:

Edwin, a 69-year-old male, presents to the clinic with a chief complaint of fever, chills, cough, fatigue, and chest pain. He reports having a low appetite and coughing up a little phlegm. He has been taking Tylenol with minimal relief and drinking tea to help break up the phlegm. Edwin denies any recent travel or exposure to sick people.

On examination, Edwin’s vital signs include a blood pressure of 130/80 mmHg, a heart rate of 84 beats per minute, respiratory rate of 14 breaths per minute, a temperature of 103.2°F, and a pulse oximetry reading of 94% on room air. Upon lung auscultation, there are decreased rales and rhonchi in the left lower lung fields with increased fremitus and dullness to percussion. Chest x-ray shows a consolidation in the left lower lobe. These findings suggest pneumonia.


Pneumonia: Symptoms of fever, cough, fatigue, chest pain, and phlegm with radiographic evidence of consolidation point to pneumonia as the most likely diagnosis (Bartlett, 2016).
COVID-19: COVID-19 may present with similar symptoms, including fever, cough, and fatigue (CDC, 2022).
Influenza: Influenza may present with similar symptoms to pneumonia, including fever, cough, and fatigue (CDC, 2022).
Based on the radiographic evidence of consolidation and Edwin’s clinical presentation, the most likely cause of pneumonia is Streptococcus pneumoniae.


Obtain a sputum sample for culture and sensitivity testing to confirm the causative organism and guide appropriate antibiotic therapy (Bartlett, 2016).
Initiate empirical antibiotic therapy with a fluoroquinolone, such as levofloxacin, to cover both gram-positive and gram-negative organisms until culture results are available (Mandell et al., 2019).
Recommend supportive care, such as rest, fluids, and pain management, to alleviate symptoms.
Schedule follow-up appointment to monitor Edwin’s symptoms and adjust treatment as necessary.
Answers to questions:

Streptococcus pneumoniae is the leading cause of bacterial pneumonia, and it is most likely the causative organism in Edwin’s case (Mandell et al., 2019).
Edwin has no underlying medical conditions or risk factors for pneumonia, which is unusual compared to most patients who are at risk for S. pneumoniae infection (Mandell et al., 2019).
In pneumococcal pneumonia, sputum analysis indicates gram-positive diplococci with a large number of neutrophils (Mandell et al., 2019).
Other bacteria to consider in community-acquired pneumonia include Haemophilus influenzae, Mycoplasma pneumoniae, Legionella pneumophila, and Chlamydophila pneumoniae (Bartlett, 2016).
The best way to identify the pathogenic agent is through culture and sensitivity testing of sputum or blood samples (Mandell et al., 2019).
The best sputum sample comes from deep coughing, where mucus is brought up from the lower respiratory tract (Mandell et al., 2019).
The best time to get a sputum sample is in the morning, as secretions from the lower respiratory tract are more concentrated (Mandell et al., 2019).
The laboratory will determine an adequate sample by verifying that it contains fewer than ten squamous epith

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