Assignment: SOAP Note Pediatric Issue

Assignment: SOAP Note Pediatric Issue

Assignment  SOAP Note Pediatric Issue

 

Name: Chris West Pt. Encounter Number: 2098/19
Date: 3-08-2019 Age: 2 years Sex: Male
SUBJECTIVE
CC:
The child mother reports,” My son has a strange cough that sounds like he is barking which worsens at night and has a hoarse voice. He is also experiencing difficulty in breathing.”
HPI:
The mother reports that the cough and hoarse voice started two days ago and had an abrupt onset. The cough has a barking characteristic and worsens at night. The cough is partially relieved by the intake of warm fluids. The mother also reports that the child has been having a hoarse cry, high body temperature, and production of light mucus. The child also has difficulty in swallowing and is unable to feed. There has been no history of swallowing a foreign material. She had administered the child with OTC paracetamol syrup to lower the body temperature and lower symptom, which was successful for some time, but the symptoms later recurred. Mother reports that the child’s immunization schedule is up to date.
Medications:
Paracetamol syrup to lower body temperature and relieve cough symptom.

PMH
Allergies:
No known food, environment or drug allergies.
Medication Intolerances:
No intolerance to drugs.
Chronic Illnesses/Major traumas
No history of chronic illnesses. No history of birth injuries or major traumas.
Hospitalizations/Surgeries

No history of hospitalization or surgery.
Family History
Chris is the 2nd born in a family of 2. Mother reports that the first born child has asthma. Mother and father have no history of chronic illnesses. Maternal grandmother has DM.

Social History
Lives with his parents in an urban town and has not yet enrolled to kindergarten. Mother reports that the child interacts well with family members and children his age.

ROS
General
Fever, lethargic, and inability to feed.
Cardiovascular
Reports difficulty in breathing. Denies bluish discoloration of lips and nails and edema.

Skin
Denies skin discoloration, bleeding, rashes or lesions. Respiratory
Reports a barking cough, difficulty in breathing. Denies hemoptysis, and wheezing. No history of TB or pneumonia.
Eyes
Corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Unable to feed.
Denies vomiting, diarrhea, constipation, or black tarry stools.

Ears
Denies hearing loss and ear discharge.
Genitourinary/Gynecological
Denies urinary urgency, frequency, change in urine color and discomfort when passing urine.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: Assignment: SOAP Note Pediatric Issue

Nose/Mouth/Throat
Reports mucous discharge.
Denies facial swelling, nose bleeding.

Difficulty in swallowing and hoarse voice. Musculoskeletal
Denies difficulty in walking, maintaining balance and muscle swelling. No history of fracture.
Breast
Denies breast swelling. Neurological
Reports lethargy
Denies history of seizures, paralysis, or fainting.
Heme/Lymph/Endo
No history of blood transfusion. Denies night sweats, acute thirst, increased hunger and heat or cold intolerance. Psychiatric
Denies history of anxiety disorder or sleeping disorders.
OBJECTIVE
Weight 29 pounds
BMI 18.2 Temp 100.94 F BP NA
Height 2’8 Pulse 128 Resp 40
General Appearance
Child in moderate respiratory distress, lethargic and agitated.
Skin
Skin is fair, clean, warm, dry, and intact. No rashes, bruises or lesions noted.
Skin pinch goes back slowly.
HEENT
Head is symmetrical, normocephalic, and atraumatic. No lesions noted. Hair is blonde and evenly distributed. Eyes: Non-inflamed sclera and conjunctiva; PERRLA. EOMs intact. Ears: Ear canals patent, ear wax present, tympanic membrane intact. Mastoid bone non-inflamed. Nose: Clear mucous discharge present. Nasal mucosa pink; nasal septum well-aligned.
Neck: Full ROM; non-palpable cervical lymph nodes and occipital nodes. Thyroid gland normal.
Mouth: Pink and moist oral mucosa. Has 16 teeth with no cavities. Tonsillar gland and pharynx are non-erythematous.

Cardiovascular
No jugular vein distension and edema noted. S1, S2 present with regular rate and rhythm. On auscultation, heart rubs, bruits and murmurs absent. Capillary refill time 2 seconds. No central or peripheral cyanosis present.
Respiratory
Chest wall retractions during inspiration. Breathing is labored. Tachypnea. On auscultation, stridor is present during inspiration. Diminished breath sounds and crackles perceived. Wheezing absent.
Gastrointestinal
Abdomen is smooth and flat. Bowel sounds present and active in all abdominal quadrants. No tenderness on palpation, no hepatomegaly or splenomegaly.
Breast
Breasts are non-tender and have no lumps.
Genitourinary
Both testes present and palpable. No urethral discharge noted.
Non-distended bladder. Perianal sore absent, no anal fissures or hemorrhoids noted. Rectal bleeding absent.

Musculoskeletal
Poor muscle tone. Bones and spine well-aligned. Normal gait, posture and stable balance.
Neurological
Speech is not fully developed. Speaks hesitantly. Stable balance, normal gait and posture.
Psychiatric
Lethargic child. Hyperactivity, stranger anxiety and social withdrawal absent. Has a social smile.
Lab Tests
WBCs Count- 4800/ mm3
Special Tests
Pulse oximetry- 92%

Diagnosis
Differential Diagnosis
Bacterial Tracheitis: A rare cause of upper airway obstruction characterized by inflammation of the larynx, trachea, and bronchi. Patients with bacterial tracheitis present with a barking cough, hoarseness, sore throat, fever, and a high WBC count (Tristram, 2019).Respiratory findings include nasal flaring, tachypnea, retractions, inspiratory stridor, and respiratory distress (Midulla, Guidi & Barbato, 2018). Bacterial tracheitis is a possible diagnosis based on the patient’s symptoms of a barking cough, fever, hoarseness, barking cough, and difficulty in swallowing. It is also likely as per physical findings of tachypnea, retractions stridor on inspiration and respiratory distress. However, there is a negative finding of a normal EBCs count.
Epiglottis: This is an inflammation of structure located above the glottis and is caused by a bacterial infection. Acute inflammation of the epiglottis results in swelling and obstruction of the upper airway (Tristram, 2019). Symptoms often have an abrupt onset and are severe. The typical triad of epiglottis includes drooling, distress, and dysphagia. Other symptoms include temperatures of above 104 F, stridor, refusal to eat, sore throat, hoarse voice, and anxiety (Midulla, Guidi & Barbato, 2018). Cough is a less frequent symptom. Epiglottis is a probable diagnosis as per findings of difficulty in swallowing, respiratory distress, hoarse voice, and inability to eat. However, there are negative findings of drooling, very high temperatures, and cough.
Whooping cough: This is a respiratory tract infection that manifests with paroxysmal cough and caused by Bordetella pertussis. It occurs in three phases, referred to catarrhal, paroxysmal, and convalescent (Gopal, Barber & Toeg, 2019). Catarrhal phase is characterized by nasal congestion, sneezing, low-grade fever, rhinorrhea, and tearing. The second phase manifests with paroxysms of severe coughing that last for several minutes, accompanied by a loud whoop and post-coughing vomiting (Gopal, Barber & Toeg, 2019). The convalescent stage has a chronic cough which lasts for weeks. Whooping cough is a likely diagnosis based on positive symptoms of cough and rhinorrhea. However, the characteristic of a paroxysmal whoop cough rules it out as a final diagnosis.
Final Diagnosis
Croup. Croup is vital respiratory condition common in pediatrics caused by Parainfluenza viruses. It primarily affects the larynx and trachea but may also involve the bronchi (Midulla, Guidi & Barbato, 2018). It is characterized by hoarseness, barking cough, stridor on inspiration, and significant respiratory distress. Croup begins with mild symptoms of rhinorrhea, cough, low-grade fever, and a sore throat (Gates, Johnson & Klassen, 2019). After 1-2 days, there is a sudden onset of a barking cough, hoarseness, inspiratory stress, and respiratory distress (Ortiz-Alvarez, 2017). The symptoms worsen at night and mostly resolve within 3-7 days but can persist for two weeks. On physical exam, children with croup are lethargic, and agitated and have tachycardia, tachypnea, diminished breath sounds, and loss of muscle tone (Gates, Johnson & Klassen, 2019). Patients unable to feed manifest with signs of dehydration and cyanosis occurs in very severe cases. Croup is the most likely diagnosis based on the child’s symptoms of a barking cough, difficulty in breathing, hoarseness, rhinorrhea, difficulty in feeding, lethargy, and agitation. Besides, positive physical exam findings of stridor, faint breath sounds, tachypnea, tachycardia, high body temperature, poor muscle tone, and respiratory distress make it a final diagnosis.
Plan
Further diagnostic tests: Neck X-ray within 8 hours; to rule out disorders that present with stridor and to help confirm the diagnosis.
Medication:
i. Dexamethasone 10 mg IM STAT; to reduce laryngeal mucosal edema (Gates, Johnson & Klassen, 2019).
ii. Nebulized Epinephrine 0.5mL BD, diluted with 3 mL normal saline over 15 minutes; to decrease airway edema (Ortiz-Alvarez, 2017).
iii. Ibuprofen suspension 100 mg PO TDS; to lower the fever.
Non-pharmacological measures: Propping the patient to ensure airway patency and allow for chest expansion.
Oxygen therapy to promote and maintain adequate tissue perfusion (Ortiz-Alvarez, 2017).
Intravenous therapy with normal saline to rehydrate body tissues.
Health education: The mother will be advised to keep the child away from smoke as it triggers exacerbations.
She will be recommended to offer the child warm light fluids to loosen mucus.
Expose the child and offer fluids when having a fever.
Follow-up: A follow-up visit will be scheduled two weeks after discharge for evaluation of progress and identification of complications.
The mother will be advised to bring the child for immediate emergency attention if the symptoms worsen such as severe respiratory distress, high fevers, and inability to feed.

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

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!

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
• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource