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Assignment NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children

Assignment: NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children

Week 3 SOAP note- Follow up Evaluation

Patient Initials: ___AH____               Age: ___12____                                 Gender: ___F____

 

SUBJECTIVE DATA:

Chief Complaint (CC):  Episodes of altered mental status, follow up from recent hospitalization

History of Present Illness (HPI):  12-year-old African American female brought to clinic with mother for follow up evaluation after hospitalization. Two days prior, patient was at school with she became altered and had episodes of jerking movements. …

Medications:

Imipramine 25mg PO PRN- Mother reports that she occasionally takes this is she drinks a lot prior to bed. Last dose was 1 week prior to event occurring.

Trazodone PRN

Allergies: NKDA

Past Medical History (PMH):

Autism, …

Past Surgical History (PSH):  Esophagogatroduodenoscopy …

Sexual/Reproductive History: Denies onset of menarche. Denies any sexual behavior.

Personal/Social History: 

Immunization History: 

Significant Family History: 

Lifestyle: 

Review of Systems:

General: 

HEENT: 

Neck: Denies any tenderness, pain, or swelling.

Breasts: Denies pain

Respiratory: Denies difficulty breathing, or pain.

Cardiovascular/Peripheral Vascular: …

Gastrointestinal: …

Genitourinary: Denies any pain or trouble with urination.

Musculoskeletal: …

Psychiatric: …

Neurological: …

Skin:   Denies any rashes or sores.

Assignment NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children

Assignment NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children

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           Hematologic: Denies any bleeding. Mother denies bleeding disorders.

Endocrine: Denies excessive thirst. Mother states that she must encourage child to drink.

Allergic/Immunologic: Patient has seasonal allergies which she takes medication for.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: …

General: …

HEENT: …

Neck: Trachea is midline. No JVD. No masses or abnormalities present. Lymph nodes are without enlargement.

Chest: No tenderness on palpitation. No lumps or masses felt. No abnormality noted.

Lungs: Breath sounds clear and equal. Chest rise and fall symmetrical. No wheezes, rales or rhonchi present.

Heart/Peripheral Vascular: …

 Abdomen: …

Genital/Rectal: 

Musculoskeletal: 

Neurological:

Skin: 

Labs:

 

ASSESSMENT:

Diagnosis – Seizure disorder 

  • Behavioral issue r/t autism disorder- These symptoms could /…
  • Adverse medication effects- …
  • Migraine- …

 

PLAN:

Treatment Plan: …

 

Health Promotion: …

 

Disease Prevention: …

 

REFLECTION:

During this experience, I learned that the patient’s parents are more concerned than the patient. Mother was crying during this visit, feeling depressed regarding patient and the unknown diagnosis. The patient appeared to be well on this examination. However, the patient had numerous health issues, most of which were psychiatric or behavioral. Care must also be given to not only the patient, but family (Burns, et al, 2017).  Also, during this experience, I learned that there are so many factors that go into determining a diagnosis for the patient. The symptoms of this patient were complicated, so there are things to rule out prior to an official diagnosis. The children’s hospital was unable to rule these things out prior to the office visit. Follow up evaluation is needed for this patient.

References:

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L.  (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Burns, C. & Matson, J. (2017). An investigation of the association between seizures, autism symptomology, and developmental functioning in young children. Developmental Neurorehabilitation, 21(3). DOI: 10.1080/17518423.2018.1437842.

Eidlitz-Markus, T., & Zeharia, A. (2017). Symptoms and clinical parameters of pediatric and adolescent migraine, by gender- a retrospective cohort study. The Journal of Headache and Pain, 18 (80). DOI: 10.1186/s10194-017-0789-z.

Linke, A., Olsen, L., Gao, Y., Fishman, I., & Muller, R. (2017). Psychotrophic medication use in autism spectrum disorders may affect functional brain connectivity. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2 (6). DOI: 10.1016/j.bpsc.2017.06.008

Pisula, E., Pudio, M., Slowinska, M., Kawa, R., Strzaska, M., Banasiak, A., & Wolanczyk, T.  (2016). Behavioral and emotional problems in high functioning girls and boys with autism spectrum disorders: parents’ reports and adolescents’ self-reports. SAGE Journal, 21(6). Doi: 10.1177/1362361316675119.

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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