2 to 3 PAGES SOAP NOTE
Select a pediatric patient that presented to the clinic, who you examined as a nurse practitioner/ provider 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 to the clinic , 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?
•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.
◦Chapter 34, “Genitourinary Disorders” (pp. 809–843)
◦Chapter 35, “Gynecologic Disorders” (pp. 844–876)
American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. (2011). Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595–610. Retrieved from http://pediatrics.aappublications.org/content/128/3/595.full?sid=cc35023c-502d-474a-9856-bfb5e38eed54
•Cox, A. M., Patel, H., & Gelister, J. (2012). Testicular torsion. British Journal of Hospital Medicine, 73(3), C34–C36. Retrieved from the Walden Library Databases.
SOAP ANALYSIS FOR A NOSE DISORDER 1
Week 7 SOAP : Analysis for a Nose Disorder
Primary Care of Adolescents & Children -NURS – 6541N – 1
Chief Complaint (CC): A 3-year-old African American female infant presented with her mother to the clinic complaining of a cough. Mother reports that the patient has been coughing constantly every night and complaining that her throat hurts for 1 week now. The patient has also been experiencing fever up to 100.5 and she has been getting her Tylenol and Motrin, but the patient has not been responding to the drugs (Fried,M..P, 2015). . Mother states that her daughter has no developmental delays or problem, goes to day-care all day. Denies any nausea, vomiting, diarrhea, shortness of breath, wheezing, retractions or any other symptoms.
History of present conditions: The patient has been experiencing the cough for a week now and it has been occurring during the night only. The coughs can be described as wet and blocking the breathing pipes. Congestion of the nose and pain in the chest areas is a dominant characteristic. The patient’s cough improved after medication with antihistamine syrup, but after three days it worsened completely.
Allergies: No general known allergies
Immunization: Up to date
Past Medical History (PMH):
None in this case
SH: Lives with both parents and two siblings
Past Surgical History (PSH):
None in this case
Not applicable in the case
Significant Family History: The parent has a chronic asthma condition
Review of Systems:
General: Discomfort in breathing, sneezing, nasal congestion and high fever
HEENT: The patient has a normal body physique, normal development pattern, functioning body organs, normal digestion process, normal blood pressure and body temperature and no documented diseases.
OBJECTIVE DATA: Physical exam:
Vital indication B/P 113 /70; P 77 and regular; T 98.9 orally; RR 20; non-labored; Wt.: 40 lbs.; Ht: 36,5 inches; BMI 16.7 which [puts this child in the 79th percentile
General: A&O x3, NAD, appears mildly uncomfortable
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub, or a gallop; pulses+2 bilat pedal and +2 radial
Neuro: CN II – XII wholly integral, DTR’s integral
BD: benign, nabs x 4, no organomegaly; slight suprapubic sensitivity – diffuse – no rebound
Musculoskeletal: symmetric muscle development (Burns, C. E, et al, 2013)
Differential Diagnosis (DDx):
1. Respiratory Tract Infection
· RSV and Strep throat : Negative
The primary diagnostic is the nasal endoscopy to test the probability of second and third differential diagnostics. The case of RTI is also probable, especially a common cold or flu.
Diagnostic and treatment: The plan was to diagnose the patient with RTI and treat both rhinitis and sinusitis. There is no cure for common cold especially with children, antibiotic is not recommended unless in severe cases. This child is not currently running any fever so we advised the mother to continue to monitor her at home, a lot of rest and taking on fluids in plenty because fluid helps with moist the air passages moist which helps her cough out the mucus. We also recommended nasal saline drops or spray to each nostril to ease the nose congestion and for easy breathing; she can also be taken to the bathroom with running hot water the stem for 10 to 15 mins or use of cool mist humidifier in the child’s room when sleeping. Continue with Tylenol or Motrin that will lower the fever are advised as well (Bradley, et al, 2011).
. To manage the disease, the patient will have to consider a high level of hygiene to prevent the spread of the disease and maintaining a warm clothing routine (NHSChoices, 2014). Provided the mother information on critical signs and symptoms of worsening condition to watch for and when to call her provider.
F/u in 2 to 3 days if symptoms does not improve.
The “aha” moment is when the patient explained that she was having nasal congestion and high fever accompanied by sneezing in the morning and in the evening. Through this, I recalled the symptoms of influenza, common cold, and flu under the envelope of Respiratory Tract infections (RTIs). Using the fact that the patient has no record of allergies that may be mistaken for RTI, the patient was probably suffering from RTI.
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier
Fried, M. P. (2015). Introduction to Nose and Sinus Disorders. Merck Manual.
NHSChoices. (2014). Respiratory Tract Infections. NHS Health A-Z
Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., … & St Peter, S. D. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, cir531.
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