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NURS 6541 Assignment: Practicum SOAP Note- Comprehensive

NURS 6541 Assignment: Practicum SOAP Note- Comprehensive

 

Particulars of the Patient

Patient Initials: TT

Age: 13 years-old

Gender: Female

Subjective Data

CC:  “Instances of changing mental status” based on a follow up from past hospitalization

HPI: TT is a 13-year-old black-American female presented to the care facility by the mother for medical evaluation after past hospitalization. The patient experienced altered mental status and had episodes of jerking movements two days before she was brought to the hospital. As per the mother’s report, during the jerking movements, TT did not respond to fellow students or teachers but just stared at them. However, TT has no memory of the occurrences of such episodes. While at the emergency room for evaluation, the patient had several episodes of jerking movements and two occurred during hospitalization. The mother, on the other hand, reports one episode with the child ever since she was discharged from the facility. TT has a past medical history of eczema, depression, autism and asthma. Upon evaluation, the patient was discharged with a follow-up schedule recommended for primary pediatrician appointment to investigate the EEG. Upon discharge, the patient’s mother states her worries with the likely of the reoccurrence of jerking movements and opines that no episodes have ever occurred to child in the past. TT reports that no pain or any clinical manifestations occurs before the onset of the episodes. The mother is concerned that the jerking movement last for several minutes before it subsides. Upon further evaluation, TT had a GCS of 10 on the day of first admission at the emergence room and on the second day, she was responsive to pain. Mother affirms that the patient was “floppy” as she walks and TT’s speech tends to be garbled when the jerking movements commences. The patient’s mother does not report current changes in the medication and affirms that she stopped giving the child the prescribed medication in a presumption that the side effects of these drugs led to these jerking episodes. The hospital of previous admission sent the medical summary of the patient but failed to provide the discharge summary or the results of the current medical investigations.

Medications: Albuterol inhaler PRN, Advair 2 puffs BID, Singulair 5 mg PO at bedtime, Flonase 1 spray each nostril daily, Paroxetine 30mg PO at bedtime, Trazodone PRN and Imipramine 25mg PO PRN – (Patient’s mother reports that TT often drink the medication before sleeping. However, the patient took the prescription drug one week before experiencing episodes of altered mental condition).

Allergies: NKDA

PMHx: Developmental delay, asthma, anxiety, autism, eczema, multiple environmental allergies, depression and preterm birth reported at 32 weeks gestation with a weight of 3lbs 12oz.

PSHx:  Esophagogatroduodenoscopy for reflux before one year post-partum.

GYN Hx: Does not report incidence of menarche. No sexual behavior reported.

Soc. Hx: No history of alcohol, tobacco or drug use. TT is enrolled in a special needs class due to her condition in school. Patient reports good appetite and the mother affirms that TT is not a picky eater.

Immun. Hx: Immunizations are up to date. Was given pneumonia and flu shots in this past Winter.

Fam Hx: Patient’s mother has medically diagnosed rheumatoid arthritis, migraines, fibromyalgia, hyperlipidemia, GERD, and anxiety. History of seizures in the paternal great uncle together with maternal aunt. Reported history of lymphoma, heart disease as well as mitral valve prolapse in grandparents.

Lifestyle: TT lives with mother and siblings with all being members of the Pentecostal faith.  Mother reports that TT’s father is against the idea of the patient taking a lot of prescription medications. Patient’s home has electricity and running water. TT is enrolled in a special needs school and reports being bullied in the institution in the past.

Review of Systems:

General: TT does not report any pain. No symptoms stated. TT denies feeling funny at any moment. No changes in appetite or weight as reported by the mother. Patient orally took Imipramine one week before the beginning of these episodes. Mother locks all the patient’s medications and does not excess intake of these prescription drugs.

HEENT: TT reports headaches between one and two weeks before the onset of jerking episodes. She does not use any glasses or

NURS 6541 Assignment Practicum SOAP Note- Comprehensive

NURS 6541 Assignment Practicum SOAP Note- Comprehensive

contacts for vision. Patient does not report any problem with hearing or seeing. No reported drainage and irritation to either ears or eyes. No loss of smell. No difficulty in swallowing. Patient’s mother reports that TT has regular appointments for eye and dental examinations.  Mother opines that when jerking episodes occur, TT stares off blankly to members of the family or health provider at her care without uttering any word. Mother reports garbled speech for the patient during the jerking movement.

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Neck: Non-tender, painful, or swollen.

Breasts: No pain reported

Respiratory: No difficulty breathing, or nasal pain.

Cardiovascular/Peripheral Vascular: Swelling and pain is not reported in all extremities.

Gastrointestinal: Mother reports good appetite for the child.

Genitourinary: No pain or difficulty in urination.

Musculoskeletal: When jerking movements occur, patient fails to walk. Upon admission, TT was able to walk though was unsteady at the initial stages. She, however, does not report any pain during walking today. Patient’s mother confirms that TT experienced jerking movements in her extremities.

Psychiatric: A history of depression is identified in the patient as a results of school bullying. TT also reports a medical history related to autism. No depression or any incidence of suicidal ideation as reported by the patient.

Neurological: No reported alterations in patterns of sleep. TT affirms good sleep at night. Patient’s mother reports that TT fails to respond to anybody during her jerking movement episodes. However, mother affirms that the patient gets back to her normal mental status immediately after jerking movements. Patient also reports occurrence of headache 1-2 weeks before jerking episodes.

Skin: No sores or rashes.

Hematologic: No any bleeding incidences. Mother does not report bleeding disorders.

Endocrine: Does not report excessive thirst. Patient’s mother indicate that she pleads with TT to drink.

Allergic/Immunologic: Seasonal allergies reported by the patient and she takes prescription medication for conditions.

Objective Data

Physical Examination

Vital signs: BP 112/78, Respiration 20, Heart rate 88, Temperature 98.7, oxygen saturation 100% ra. Height 4’9”, weight 821lbs, BMI 18

General: Patient is a well-kept African American female and has a good hygiene. While sitting on examination room, she also plays on an IPAD at the table as the mother sits on a chair in room. Patient alert and is oriented x3.

HEENT: Head: PERRLA

Eye: conjunctiva clear, sclera white.

Throat: No dental caries identified. No swollen tonsils.  Posterior pharynx does not have exudate or redness.

Ear: Nares patent bilateral. No identified drainage at the bilateral nares. Bilateral TMs does not bulge and is without any redness towards the middle ear canal.  No drainage identified in the bilateral ears.

Neck: Trachea is midline. Neck supple. No JVD. No lymphadenopathy. Lymph nodes not enlarged.

Chest: Non-tender to palpitation. Does not have masses or lumps. No abnormality identified.

Lungs: Clear and equal breath sounds. Chest rises and falls symmetrically. No rales, rhonchi or wheezes.

CV: Heart rate 88. S1, S2 RRR auscultated without murmurs. No edema or swelling on bilateral feet or hands. Pulses bounding and strong as identified in all the four extremities.

 Abdomen: Non-distended and no pain on palpitation. Normal bowel sounds in all 4 quadrants. Non-tenderness.

Genital/Rectal: Not assessed. No pain or problems reported by patient.

Musculoskeletal: Full ROM and no deficits identified. Normal reflexes. Muscle strength noted at 5/5.

Neurological: DTR intact. CN II- XII intact.

Skin: Dry and warm to touch. Epithelial tissue intact. No lesions or rashes identified.

Labwork:

UA: Urine drug screen positive for Tricyclic antidepressants. Protein of 30.

CBC: WBC 6.5, Hgb 13.6, Ptl 370, Hct 41.6.

CMP: Sodium 141, BUN 11, Potassium 4.6, CR 0.5, AST 24, glucose 95, ALT 20.

CT scan: no abnormalities on head.

Assessment

Dx:

  • Primary diagnosis

Seizure disorder: The condition is based on episodes of jerking movement as observed in the extremities during hospitalization of the patient (Frye, 2016). The mother also affirms these episodes and they are the main reasons for the hospitalization of the patient. Often, manifestations of seizure disorders vary and are identified as focal, febrile and epileptic seizures (Dabney et al., 2016). As per the case presented, the patient experienced multiple episodes of jerking movements in her extremities and she was nonresponsive to her environment.

  • Secondary diagnosis

Autism disorder: This is related to behavioral issues as identified by the defiant nature of the adolescent despite the presence of a mental issue observed through episodes of seizures (Kanfiszer, Davies & Collins, 2017). The patient has a history of jerking movements and also act out towards her parents especially when she becomes mute during the episodes of seizures.

  • Differential diagnosis
  1. Adverse medication effects related to tricyclic antidepressants as well as other medications prescribed to the patient (Rausch et al., 2018). There is a probability that the adolescent is taking the medications with her mother’s knowledge. The medication has adverse effects and must be adjusted as per the changes in weight of the patient.
  2. Migraine related to experiences of headaches 1 to 2 weeks before the episodes of seizures. Migraines manifests through nausea, photophobia, pain, and dizziness (Balestri et al., 2018). Migraine may develop by the onset puberty.

Plan

Treatment Plan

An appointment has been made with a neurologist to address autism disorder. Patient’s mother encouraged to make an earlier appointment to manage the condition and she settles on 2.5 months from the date of clinic. In the next visit, an EEG will be investigated in order to rule out the possibility seizures that causes jerking movement (Frye, 2016). The mother is advised to keep all the prescription medications away from the patient and only administer the same at the right time to avoid misuse. Mother is instructed to make an appointment with a psychiatrist for mental evaluation of the child (Kanfiszer, Davies & Collins, 2017).

Health Promotion

Encourage the patient to engage in physical and academic activities undertaken in the school. This corresponds to body changes that occurs among adolescents. Advise the mother and the patient on the benefits of healthy dietary choices (Dabney et al., 2016). Encourage the patient to increase the intake of iron and calcium for blood and bone development (Rausch et al., 2018). Advise the patients to get enough rest and sleep.

Disease Prevention

Encourage immunizations for patient particularly DTaP, HPV, pneumonia and influenza. Also recommend patient’s psychological status during health examinations (Kanfiszer, Davies & Collins, 2017). Besides, evaluate the school performance and relationship with peers for the adolescent (Dabney et al., 2016). It is also recommended that adolescents at the age of the patient seek annual health examinations to screen diseases for prompt treatment.

Reflection

In this study I realized that the patient’s mother was more concern with TT’s health status than the patient. It was identified that mother wept as she presented the adolescent for examination as she was concerned about the unidentified diagnosis. The patient, however, did not report pain but on further examination, she had psychiatric and behavioral disorders (Balestri et al., 2018). Based, on the case presented, I learned that care services need to be administered to the family of the patients as well. Furthermore, from the evaluation of the patient, I realized that several factors play key roles in the development of a diagnosis for patients. Besides, patients manifest different symptoms which complicates diagnosis of illness. As such, follow-up evaluations are recommended for further examination of diseases in the children’s hospital.

Assignment: Practicum – SOAP Note #3: Comprehensive
Your Well Child Note is due by Day 7 of Week 8. Take some time to review the provided example. Select a patient who you examined during the last 4 weeks. With this patient in mind, address the following in a SOAP Note:
• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

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