(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking)

(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at night, fatigue and gets winded daily while walking) eGENITOURINARY: N/A NEUROLIGICAL: No headache or dizziness MUSCULOSKELETAL: N/A HEMATOLOGIC: N/A LYMPHATICS: No reports of enlarged lymph nodes PSYCHIATRIC: N/A ENDOCRINOLOGIC: N/A SKIN: N/A Differential Diagnoses: Pneumonia (ICD-10, J18.9): Community-acquired pneumonia can be either viral or bacterial. S. pneumoniae is the most common cause. S. pneumoniae is a gram-positive organism that naturally lives the upper respiratory tract, colonizes the upper respiratory tract and can cause wide spread invasive infections, pneumonia, upper and lower respiratory infections such as rhinosinusitis and otitis media. Influenza virus is the most common viral cause of pneumonia. The virus destroys epithelial cells and invades goblet cells and bronchial mucous glands, which weaken defenses as sloughing of the bronchial epithelium cells begin. Symptoms begin to show as the body is trying to fight off the invading organisms. White blood cells and other chemicals from the immune system arrive to the site invading the organisms. This will impair oxygenation and produce typical signs and symptoms of pneumonia including; low grade fever, cough, and dyspnea. Others symptoms can include; chills, malaise, and pleuritic chest pain (Severson, Renstrom, & Fitzhugh, 2012). Katie is complaining of a cough for over one week that is worse at night along with chest pain (pleuritic). She also states she is tired and is short of breath. Katie’s symptoms support the diagnosis of pneumonia thus