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PRAC-6541-24,Primary Care of Adol & Child.2020 Summer Qtr 06/01-08/23-PT27•Assignment 1 - Week 6•Submitted on Sun, Jul 12, 2020, 7:29 PMView Originality Report - Old Design

Helen Sulonteh

View Report Summary

Running Head:

s Helen’s SOAP NOTES 1

Helen’s SOAP NOTES 7

Helen’s SOAP

Helen Sulonteh

Walden University

PRAC-6541

Mrs Ladd

Patient Initials:

LK Age:

4 Gender:

F SUBJECTIVE:

1

Chief Complaint (CC):

A patient-reported with a complaint that her right ear hurts.

1

History of Present Illness (HPI):

L.K is a Caucasian female who is 4-years of age.

She presented to the hospital with her mother.

The mom indicated that for the last three days L.K.

had been tugging on her right ear.

2

When LK woke up in the morning, her mother indicated she was looking pale and felt warm but never had a thermometer to take her temperature.

Mom said that she gives L.K.

ibuprofen.

Mom also reported that LK had a cold almost 2 weeks ago, with yellow drainage and a cough, a recent loss of appetite.

She had a fever a few days ago, but the mother was not sure of the patient’s current temperature.

Medications:

1.

Tylenol as required 2.

Ibuprofen as required

3.

Children’s multivitamin as requires

4.

Zyrtec

Allergies:

NKDA

1

Past Medical History (PMH):

3

Had Allergic rhinitis Past Surgical History (PSH):

No surgical history Reproductive History:

No sexual history Personal History:

2

L.K stays at home with her 7-year old brother, 27 year old mother, and 29 year old father. LK is in kindergarten who attends school 7 hours a day.

She is a well-performing pupil and has diverse friends and has never reported any issue with her classmates.

She comes from a family that feeds on a balanced diet.

She takes pleasure in riding around her bicycle with a helmet on, spends half an hour playing games using her tables, and watches TV every night.

She sleeps around 8-10 hours every day.

2

The parents do not take drugs or drink alcohol.

According to the mother, L.K.

wears her seatbelts all the time and sits in a booster seat that faces forward on the backseat.

Immunization History:

LK immunizations are updated except the fifth dose of the DTaP.

2

The 4th Poliovirus dose, 2nd Varicella, and 2nd MMR will be taken the next child visit at the end of the month.

She has received her influenza vaccination for the current year.

2

Significant Family History: The client's brother who is 7-year old has seasonal allergies. The maternal grandmother is suffering from cancer, while the maternal grandfather is suffering from an illness with no known origin.

3

The paternal grandmother is diabetic and the paternal grandfather has hypertension, alcoholism, and hyperlipidemia.

2

The mother and father have no medical history.

Lifestyle:

She attends church activities and plays games with her toys with her brother.

1

Review of Systems:

HEENT:

4

complains of pain in right ear;

denies having problems hearing;

denies having problems with vision;

5

no drainage from ears, nose or throat;

no redness in throat;

denies having cough;

denies having throat pain or discomfort.

Respiratory:

2

the patient denies of having shortness of breath;

CV:

4

denies having chest pain.

GI:

6

denies having vomiting or nausea.

The mother reports her having a poor appetite in last 3 days.

GU:

denies having problems urinating;

denies having blood in urine;

denies having pain when urinating.

Allergic:

Complains of having seasonal allergies

Physical Test:

Vital signs include:

2

P 82 and regular; 98/64 B/P, left arm, small cuff, sitting;

7

T 99.9 orally;

Wt:

43 Ibs;

BMI:

24.67;

RR 16;

Ht:

35”;

SPO2 99% The general signs:

2

A&O x4 seems to be mildly uncomfortable and pale.

The patient is sedentary on the laps of her mother.

The effects are suitable for the age and also able to illuminate the pain of the right ear.

Well-dressed properly.

2

She walked towards the test table, and a normal gait was noted.

HEENT:

2

Hair is distributed evenly, and the head is normo-cephalic. Pale pink conjunctiva, PERRLA, sclera white, bred reflux bilaterally present. No sclera or conjunctival injection. Otoscope test on right comprises protruding tympanic membrane and erythema with mobility that is limited. With the left ear having an otoscope, there is clear tympanic membrane, redness, no edema. Identification of landmarks visible when in a neutral position. Turbinate’s of Nasal are enlarged slightly with yellow bilaterally rhinorrhea. Negative maxillary sinuses for percussion tenderness (Kaur et al., 2017).

Trachea midline.

2

Negative presence of edema on throat, drainage, exudate, or erythema.

Neck:

2

No neck palpation for lymphadenopathy or the clavicular area.

Appropriate ROM.

Lungs/chest:

2

The symmetrical chest expansion. Clear sounds from the lung's all lobes. Absence of rales, wheezing, or eminent rhonchi in expiration or inspiration.

No fitment muscles used during breathing.

Cardiovascular:

2

Eminent S1 & S2 heart sounds. Absence of eminent extra or murmurs heart sounds. Refill of capillary < 3 seconds, no cyanosis or clubbing observed. Pulses equivalent to x2 extremities.

The abdomen:

Lack of tenderness during palpation, and non-distended.

2

Hypoactive bowel sounds x4. Absence of hernias or masses.

Negative McBurney’s.

EVALUATION:

Diagnostics:

Head to Toe Assessment;

Otoscope used to observe the inner ear, throat and nasal passage.

Primary Diagnosis

Based on the finding on the test I conducted, acute otitis media is the primary diagnosis.

There was a bulged tympanic membrane and erythema with restricted mobility.

2

The typical symptoms of acute otitis media are fever, decreased appetite, and vomiting, or nausea (Venekamp , 2015).

The patient’s mother indicated the patient had a fever and loss of appetite.

Currently the patient has a temperature of 100.6 (low grade).

2

Differential Diagnosis Otitis Media with Effusion (OEM). According to the 2018 CDC, OME is sticky or thick fluid in the middle ear before the eardrum, where it occurs with no ear infection, which is caused by dysfunction of the eustachian tube.

The patient in this scenario had no fever.

This was ruled out because only pain was reported with no drainage.

8

(Hoberman et al., 2016).

9

Acute Bacterial Sinusitis.

Symptoms of this disorder may be frontal cavities on sinus, maxillary tenderness, and headache.

Other symptoms may be congestion of edematous with nasal cavities (Fortanier et al., 2019).

The patient's mother claimed that the patient was recovering from a cough 2 weeks ago.

No history of sinusitis was reported.

Cold and Dysfunction of Eustachian tube- This could have caused the ear pain.

However, the cold occurred two weeks ago and there was no pain until 3 days ago.

PLAN:

2

Due to the patient's allergic rhinitis, she should take 5 mg of Zyrtec daily.

10

She was encouraged to reduce disclosure to allergens like mold, pollen, dust, pet dander, etc.

11

The antibiotic for Acute Otitis Media is amoxicillin.

2

The MS dosing is 90mg for each kg ten days two times a day.

Prescriptions are 9ml BID for ten days, 400mg/5ml, 180ml dispensation without refills.

For pain and fever, the parent was advised to give the patient Tylenol for children liquid (10 ml, 3 times daily).

2

Disease Prevention/ Health Promotion:

Explained the relevance of keeping up with vaccinations, which includes the vaccine of influenza.

Check-ups should be annually and dental tests after six months (Norhayati et al., 2017).

2

Also, it explained the relevance of conserving a healthy diet, were also explained unhealthy diet negative effects.

Reflection:

After the evaluation of the patient, I have learned that fever, decreased appetite, and vomiting, or nausea may be symptoms of acute otitis media.

References

Fortanier, A.

12

C., Venekamp, R. P., Boonacker, C. W., Hak, E., Schilder, A. G., Sanders, E. A., & Damoiseaux, R.

A.

(2019).

12

Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database of Systematic Reviews, (5).

13

Hoberman, A., Paradise, J. L., Rockette, H. E., Kearney, D. H., Bhatnagar, S., Shope, T.

R.,...

& Block, S.

L.

(2016).

11

Shortened antimicrobial treatment for acute otitis media in young children.

13

New England Journal of Medicine, 375(25), 2446-2456.

14

Kaur, R., Morris, M., & Pichichero, M.

E.

(2017).

14

Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era.

Pediatrics, 140(3).

Norhayati, M.

12

N., Ho, J. J., & Azman, M.

Y.

(2017).

11

Influenza vaccines for preventing acute otitis media in infants and children.

12

Cochrane Database of Systematic Reviews, (10).

Venekamp R.P., Sanders, S.L., Glasziou, P.P., Del Mar, C.B., Rovers, M.M.

(June 2015).

11

Antibiotics for acute otitis media in children..

15

The Cochrane Database of Systematic Reviews.

6 (6):

CD000219.

highRisk Created with Sketch.

Attachment 2WK6ASSIGN1_SulontehH 2.docx63%

Sources

Included sources

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• Institutional database (11)

  56%

  • Internet (2)

    5%

    • Global database (2)

      1%

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        Word Count:	Submitted on:	Submission UUID:	Attachment UUID:
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