Admitting History A 60-year-old man with respiratory

Admitting History A 60-year-old man with respiratory distress was admitted to the emergency department. He reported worsening shortness of breath of several years’ duration and was currently on total disability because of his pulmonary problems. He had worked on the mine face in a Kentucky coal mine for 35 years. About 15 years ago, he was told that he had “black lung” disease. At that time, he quit smoking—a habit he had had for 30 years. He had a mild, nonproductive cough for many years. Physical Examination The physical examination revealed severe digital clubbing, distended neck veins, and pitting edema over his ankles. His respiratory rate was 33/minute, heart rate 105/minute, and blood pressure 146/100. Breath sounds were described as “distant,” and there were wheezes and course crackles bilaterally. A chest x-ray examination showed 1-3-mm rounded opacities scattered throughout all lung fields and moderate enlargement of the right side of the heart. Arterial blood gases (ABGs) in room air were pH 7.39, PaCO2 68, HCO3( 46, and PaO2 54. His bedside forced vital capacity (FVC) was 50% of predicted. His slow vital capacity was 70% of predicted. The patient had a history of both a restrictive and obstructive lung disorder. At this time a respiratory assessment and plan were entered into the patient’s chart. Based on the above clinical data, how would you SOAP this patient? (SOAP 1)

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