week3-B

Helen’s FirstSOAP Note

June 17, 2020

PEDIATRIC EPISODIC SOAP

Patient Initials: J.K Age: 9 Gender: Male

Subjective Data: The patient is a nine-year-old male of African American origin. The patient’s mother provides the information that the patient has been wheezing a lot in the past. The parent also observed that the patient started complaining of shortness of breath in the morning. History of Present Illness: One of the symptoms is wheezing, which affects the airway in any location. The onset of the symptom has been the recent past, while the wheezing has been intense. No signs and symptoms have been seen to accompany the wheezing. On timing, the wheezing has been happening at any time of the day or night. Some relieving factors for the wheezing include taking warm drinks and pursed-lip breathing. The severity of the symptom varies. Comment by priya: Missing chief complaint -1 Also the info under “subjective data “ is unnecessary because should be in hpi Comment by priya: This is not presented by patient, so no need to state this

The other symptom is shortness of breath, which affects the lungs. The onset of the symptom was this morning, while the character has had an intense tightening of the chest. No associated signs and symptoms have featured alongside the ailment. On timing, the shortness of breath has been occurring at any time of the day. The relieving factor for the disease is engaging in physical exercises. The symptom has been severe to the extent that the patient complained. Comment by priya: This is not presented by patient, so no need to state this

Medications: The short-term pharmacological treatment for managing the symptoms would include Proventil HFA 108 (90 bases) MCG/ACT inhalation aerosol solution, 1-2 puffs every 6 hours as needed for SOB or wheezing (use with prescribed spacer), montelukast sodium 4mg oral, 1 tablet daily at bedtime, albuterol sulfate 0.63 mg/3ml inhalation nebulization solution every 4 hours as needed for SOB or wheezing.

Allergies: The patient has no history of allergies

Past Medical History: The patient had previously suffered from Asthma

Past Surgical History: The patient has not undergone surgery in the past

Immunization History: The patient has been immunized for all scheduled ailments since birth

General: Comment by priya: ROS is missing MANY body systems. -5

Respiratory: Shortness of breath, wheezing

Chest: abnormal shape

The patient’s history obtained from his parent is that the former has previously been on medication for some respiratory disorder. The patient has, however, been out of medication for weeks, hence the symptoms. The patient did not offer any information regarding their medical history, and no discrepancy, therefore, featured in the information presented. Comment by priya: This should be mentioned in the hpi, it is out of place here

Objective: Comment by priya: Missing vital signs -2 Not organized by body system next time don’t put in paragraph form as a commentary. Remember this is to be objective and if written in paragraph form it is in 3rd person. Additionally, no need to cite info because you are not putting outside source info here, but instead you are making observations from your patient. -4

Physical Test: Some observations that I made during the physical assessment of the child included hyperexpansion of the thorax, appearance of hunched shoulders as well as chest deformity. In a similar manner, I noted wheezing sounds during both normal breathing and forced exhalation (Nunes et al., 2017). Other observations included increased secretion of the nasal, mucosal swelling, and nasal polyps. The patient also appeared to have an allergic skin condition. Comment by priya: Describe, don’t say normal/abnormal -1 Comment by priya: Describe, don’t diagnosis here -1

Diagnostics: The spirometer test results were, however, normal or near-normal hence the need to trigger the asthma symptoms. The patient did not, however, present with any growth challenges. Similarly, the patient did not have a history of psychosocial problems, although he faced challenges relating to the expression of self.

Assessment: One differential diagnoses for the patient would be chronic obstructive pulmonary disease (COPD). The disease involves symptoms that closely resemble those of Asthma, such as long-term breathing problems and poor airflow. The ailment’s primary symptoms include shortness of breath as well as a cough that involves the production of sputum. The other differential diagnosis would be hyperventilation syndrome and panic attacks. Some symptoms of the ailment that can easily be confused with Asthma include rapid, deep breathing and hyperventilation. Notably, the latter gets worse even after trying home care options. The other symptom that may also be confused for Asthma is frequent sighing. The third differential diagnosis would involve Congestive heart failure; a disorder consists of some symptoms that resemble those of the asthma exacerbation. Some symptoms therein include shortness of breath, mainly when one lies down, irregular heartbeat as well as fatigue, and weakness. Other symptoms include reduced ability to exercise and persistent cough or wheezing. Previously, the patient was diagnosed with Asthma, which has since not been controlled. Comment by priya: This section is worth 30 points and requires that you not only state a description of each priority and differential dx but also relate it back to your pt's HPI/exam findings (to either prove why you are keeping or ruling out the dx). Additionally, for the differentials you must state why you included the differentials if you were eventually going to rule out. - poorly organized - m issing relation back to pt’s hpi/exam - missing source citaiton -15

Plan: The diagnostic plan for the patient is the discussion of the patient’s medical history with him and his parent as well as the execution of a physical exam. Some tests that would suffice for the patient include the lung function test and sinus X-ray. The primary diagnosis of Asthma is to be based on instances of episodic breathing difficulties and variable but reversible obstruction of the patient’s airway. Comment by priya: Missing source citation -1

Treatment Plan: Pharmacological treatment of the ailment would include the use of either bronchodilators or anti-inflammatory therapy. One medication that falls under the former category includes adrenoceptor agonists such as fenoterol and salbutamol. The other potential medication is anticholinergics, which is responsible for the relaxation of airway smooth muscle. Anti-inflammatory therapy, on its part, would include medications such as prostanoids, histamine, cytokines, and chemokines.Non-pharmacological treatment, on the other hand, would include, among others, avoidance of tobacco smoke exposure, increased physical activity, well-balanced, healthy diet, and the avoidance of medication(s) that lead to adverse asthma symptoms (Strandbygaard et al., 2010).

Health Promotion: The patient should engage in regular exercise to increase lung capacity and reduce inflammation therein. On a diet, the patient should eat to maintain a healthy weight. Similarly, the patient should eat plenty of fruits and vegetables to obtain anti-oxidants such as beta carotene and vitamins C and E. To be safe; the patient should avoid foods that can potentially trigger allergic reactions. Moreover, foods rich in vitamin D should form part of the patient’s regular diet. Above all, the patient should avoid sulfites as they can potentially trigger Asthma in some patients. Comment by priya: Missing source citation -1

Disease Prevention: Follow up activities would include the execution of several tests, including lung function tests, chest radiograph, laboratory tests. The other essential activity therein would involve proposing methods for monitoring side effects and adherence to treatment. It would also be necessary to offer approaches for adjusting long-term therapy. Monitoring the side effects of treatment and adherence would also be essential as part of follow-up activities. The rationale for the follow-up and management plan would be, among others, fewer symptoms, little use of quick relief, and taking asthma medicines with little or no side effects. In a similar manner, the measures would ensure that the patient can take part in daily and routine activities and prevent asthma flare-ups (Pavord et al., 2018). In a nutshell, a patient on who the medication and follow-up have been undertaken may not require emergency room or hospital care.

Reflection: My “aha” moment in the course of diagnosis was the mention of the wheezing and shortness of breath. Remarkably, the symptoms are some of the primary defining signs of Asthma. In case I was to undertake the evaluation again, a thing that I would do differently is inquiring about a long history of the patient’s medical condition. Some questions that I would pose to the patient and his parent would include: when do the symptoms occur? Does anything seem to trigger the symptoms? Is the patient exposed to tobacco smoke or chemical fumes? Do other relatives feature asthma or allergy problems? What medications were you taking previously? Do you suffer from any sort of fever or allergic condition? The physical assessment of the patient would involve the examination of the patient’s nose, throat, and upper airways. Above all, I wouldcarry out a spirometry test to determine if the patient’s lung functionality.

References

Nunes, C., Pereira, A. M., &Morais-Almeida, M. (2017). Asthma costs and social impact. Asthma research and practice, 3(1), 1.

Pavord, I. D., Beasley, R., Agusti, A., Anderson, G. P., Bel, E., Brusselle, G., ... & Frey, U. (2018). After Asthma: redefining airways diseases. The Lancet, 391(10118), 350-400.

Strandbygaard, U., Thomsen, S. F., & Backer, V. (2010). A daily SMS reminder increases adherence to asthma treatment: a three-month follow-up study. Respiratory medicine, 104(2), 166-171.

Subjective(25points)
●              CC	1
●              PertinentpositivesLOCATES	10
●              Pertinentnegatives(fromROS)	10
●              PertinentPMH,SH,andFH	3
●              Medicationsanddrug/foodallergiesarenotincluded	1
Objective(20points)
●              VSincludingBMI	2
●              Heartandlungs	1
●              Systemsorspecialtyexamtechniquesthatarenotnecessarytoarriveatadiagnosisareincluded.	5
●              Systemsorspecialtyexamtechniquesthatarenecessarytoarriveatyourdiagnosisareomitted.	10
●              Diagnostictestresults	2
Assessment–10pointsfor eachpriority diagnosis(total30points)Support your selection with rationales keeping in mind the likelihood of each subsequent diagnosis based on the patient’s age, gender, and race, risk factors, lifestyle choices, and co-morbidities. (30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities	/30
Plan(15points)
●              Medicationsdiscontinued("d/clisinopril10mgdaily”)	1
●              Medications started(“startAvapro 150mgdaily”)	2
●              Alternativetherapiesifappropriate(1point)	1
●              HealthPromotionstrategies–patient/familyeducation	3
●              DiseasePreventionstrategieswithtimeframeifappropriate	3
●              Diagnostictestsorderedwithtimeframe(now,in2weeks,priortof/uvisitin3months)	3
●              Referralsorconsultationsifappropriate	1
●              Follow-upinterval	1
Reflectionnotes(10points)
●              What didyoulearnfromthisexperience?Any ah-ha’s?	10
Totalpoints		69/100