week6

OriginalityReport-new.pdf

7/14/2020 Originality Report

https://class.waldenu.edu/webapps/mdb-sa-BBLEARN/originalityReport/ultra?attemptId=4cf1b26b-4a2b-41ac-9efa-1c2da8d5b5fe&course_id=_16696… 1/8

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SafeAssign Originality Report PRAC-6541-24,Primary Care of Adol & Child.2020 Summer Qtr 06/01-… • Assignment 1 - Week 6

%32Total Score: Medium risk Helen Sulonteh

Submission UUID: 20e7684b-68ba-f7fc-6ef5-a305882b73ce

Total Number of Reports

2 Highest Match

63 % WK6ASSIGN1_SulontehH 2.docx

Average Match

32 % Submitted on

07/12/20 07:29 PM EDT

Average Word Count

685 Highest: WK6ASSIGN1_SulontehH 2.docx

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Source Matches (0)

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Institutional database (11)

Student paper Student paper Student paper

Student paper Student paper

Internet (2)

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Global database (2)

Student paper Student paper

Top sources (3)

Excluded sources (0)

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Running Head: s Helen’s SOAP NOTES 1

Helen’s SOAP NOTES 7

Helen’s SOAP

Helen Sulonteh

Walden University

PRAC 6541

https://class.waldenu.edu/webapps/mdb-sa-BBLEARN/originalityReport?attemptId=4cf1b26b-4a2b-41ac-9efa-1c2da8d5b5fe&course_id=_16696106_1&includeDeleted=true&print=true&force=true

7/14/2020 Originality Report

https://class.waldenu.edu/webapps/mdb-sa-BBLEARN/originalityReport/ultra?attemptId=4cf1b26b-4a2b-41ac-9efa-1c2da8d5b5fe&course_id=_16696… 2/8

PRAC-6541

Mrs Ladd

Patient Initials: LK Age: 4 Gender: F SUBJECTIVE: Chief Complaint (CC): A patient-reported with a complaint that her right ear hurts. 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. 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

Past Medical History (PMH): Had Allergic rhinitis Past Surgical History (PSH): No surgical history Reproductive History: No sexual history Personal History:

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

mother and father have no medical history. Lifestyle: She attends church activities and plays games with her toys with her brother. Review of Systems: HEENT:

complains of pain in right ear; denies having problems hearing; denies having problems with vision; no drainage from ears, nose or throat; no redness in

throat; denies having cough; denies having throat pain or discomfort. Respiratory: the patient denies of having shortness of breath; CV: denies having chest

pain. GI: 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: P 82 and regular; 98/64 B/P, left arm, small cuff, sitting; T 99.9 orally; Wt: 43 Ibs; BMI: 24.67; RR 16; Ht: 35”; SPO2 99% The

general signs: 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. She walked towards the test table, and a normal gait was noted. HEENT: 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. Negative presence of edema on throat, drainage,

exudate, or erythema. Neck: No neck palpation for lymphadenopathy or the clavicular area. Appropriate ROM. Lungs/chest: 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: 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. 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.

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There was a bulged tympanic membrane and erythema with restricted mobility. 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). 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. (Hoberman et al., 2016).

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: Due to the patient's allergic rhinitis, she should take 5 mg of Zyrtec daily. She was encouraged to reduce disclosure to allergens like mold,

pollen, dust, pet dander, etc. The antibiotic for Acute Otitis Media is amoxicillin. 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). 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). 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. C., Venekamp, R. P., Boonacker, C. W., Hak, E., Schilder, A. G., Sanders, E. A., & Damoiseaux, R. A. (2019). Pneumococcal conjugate vaccines for

preventing acute otitis media in children. Cochrane Database of Systematic Reviews, (5). Hoberman, A., Paradise, J. L., Rockette, H. E., Kearney, D. H., Bhatnagar,

S Sh T R & Bl k S L (2016) Sh t d ti i bi l t t t f t titi di i hild N E l d J l f M di i 375(25)

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7/14/2020 Originality Report

https://class.waldenu.edu/webapps/mdb-sa-BBLEARN/originalityReport/ultra?attemptId=4cf1b26b-4a2b-41ac-9efa-1c2da8d5b5fe&course_id=_16696… 3/8

Source Matches (52)

Student paper 100%

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Student paper 63%

Student paper 64%

S., Shope, T. R.,... & Block, S. L. (2016). Shortened antimicrobial treatment for acute otitis media in young children. New England Journal of Medicine, 375(25),

2446-2456. Kaur, R., Morris, M., & Pichichero, M. E. (2017). Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics,

140(3). Norhayati, M. N., Ho, J. J., & Azman, M. Y. (2017). Influenza vaccines for preventing acute otitis media in infants and children. Cochrane

Database of Systematic Reviews, (10). Venekamp R.P., Sanders, S.L., Glasziou, P.P., Del Mar, C.B., Rovers, M.M. (June 2015). Antibiotics for acute otitis media in

children.. The Cochrane Database of Systematic Reviews. 6 (6): CD000219.

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Student paper

Chief Complaint (CC):

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Chief Complaint (CC)

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History of Present Illness (HPI):

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History of Present Illness (HPI)

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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.

Original source

When MS woke up this morning mom said she looked pale and felt warm, but didn’t have a thermometer to check her temperature

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Past Medical History (PMH):

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Past Medical History (PMH)

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Had Allergic rhinitis Past Surgical History (PSH):

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Seasonal allergies, Allergic Rhinitis Past Surgical History (PSH)

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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.

Original source

MS lives at home with her 7-year-old brother, mother, and father She is in kindergarten and attends a full day of school

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The parents do not take drugs or drink alcohol.

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Her parents do not drink, do drugs, but drink alcohol occasionally

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

Original source

Her immunizations are up to date, except for her 5th dose of DTaP, 4th dose of Polio virus, 2nd MMR, and 2nd Varicella, which will be given at her next well child visit at the end of next month

7/14/2020 Originality Report

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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.

Original source

Significant Family History Patient has a 7- year-old brother who has seasonal allergies, but is otherwise healthy Maternal grandmother is deceased from pancreatic cancer and maternal grandfather is deceased from an unknown origin

Student paper

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

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Paternal grandfather- Hypertension, Hyperlipidemia, Alcoholism

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The mother and father have no medical history.

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Mother and father are alive and healthy with no medical history

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Review of Systems:

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REVIEW OF SYSTEMS

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complains of pain in right ear;

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Right ear pain

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no drainage from ears, nose or throat;

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eyes- no itching, drainage, or redness, ears/nose/throat

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the patient denies of having shortness of breath;

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Denies shortness of breath or cough

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denies having chest pain.

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The patient denies chest pain or pressure

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denies having vomiting or nausea.

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Patient denies nausea, vomiting or diarrhea

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

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

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T 99.9 orally;

Original source

T 99.9

7/14/2020 Originality Report

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Student paper 82%

Student paper 75%

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

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A&O x4, appears pale and mildly uncomfortable

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

Original source

She walked to the exam table and normal gait noted

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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.

Original source

Head is normo-cephalic and hair is evenly distributed PERRLA, red reflux present bilaterally, sclera white, conjunctiva pale pink No conjunctival or scleral injection Otoscope exam on right includes erythema and bulging tympanic membrane with limited mobility

Student paper

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).

Original source

With otoscope on the left ear the tympanic membrane is clear, no edema, redness In neutral position with identifying landmarks visible Nasal turbinates are slightly enlarged with yellow rhinorrhea bilaterally Maxillary sinuses negative for tenderness upon percussion

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

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Throat negative for edema, erythema, exudate, or drainage

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No neck palpation for lymphadenopathy or the clavicular area.

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No lymphadenopathy palpated in neck or clavicular area

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

Original source

Chest expansion symmetrical Lung sounds clear in all lobes No wheezing, rales, or rhonchi noted in inspiration or expiration

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

Original source

S1 & S2 heart sounds noted No murmurs or extra heart sounds noted Capillary refill < 3 seconds, no clubbing or cyanosis observed

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Pulses equivalent to x2 extremities.

Original source

Pulses equal x2 extremities

7/14/2020 Originality Report

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Hypoactive bowel sounds x4. Absence of hernias or masses.

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Bowel sounds hypoactive x4 No masses or hernias noted

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

Original source

These are all classical symptoms of an acute otitis media as well as other symptoms, such as decrease in appetite, fever, and nausea or vomiting

Student paper

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.

Original source

Otitis media with effusion (OEM) is the first differential diagnosis that came to mind According to the CDC (2018), OME is thick or sticky fluid behind the eardrum in the middle ear which occurs without an ear infection

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(Hoberman et al., 2016).

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(Hoberman et al., 2016)

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Acute Bacterial Sinusitis.

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Acute bacterial Sinusitis

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

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Allergic rhinitis- Patient to take Zyrtec 5 mg daily and to follow up as needed

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

Original source

Inhaling allergens like dust, pollen, mold, pet dander, etc

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The antibiotic for Acute Otitis Media is amoxicillin.

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Antibiotic therapy for children with acute otitis media

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

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Dosing for MS is 90mg per kg twice a day for ten days

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Disease Prevention/ Health Promotion:

Original source

Health Promotion/Disease Prevention

7/14/2020 Originality Report

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

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Also, explained the importance of maintaining a healthy diet and the negative effects of an unhealthy diet

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

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

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A., & Damoiseaux, R.

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A., & Damoiseaux, R

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

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

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

Original source

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

Student paper

Shortened antimicrobial treatment for acute otitis media in young children.

Original source

Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children

Student paper

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

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

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

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

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

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Epidemiology of Acute Otitis Media in the Postpneumococcal Conjugate Vaccine Era

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

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

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

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Influenza vaccines for preventing acute otitis media in infants and children

7/14/2020 Originality Report

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Cochrane Database of Systematic Reviews, (10).

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Cochrane Database of Systematic Reviews, (10), CD010089

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Antibiotics for acute otitis media in children..

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Antibiotics for acute otitis media in children

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The Cochrane Database of Systematic Reviews.

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Cochrane Database of Systematic Reviews