week6

Helen’s First SOAP Note

June 17, 2020

PEDIATRIC EPISODIC SOAP

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

Chief Complaint: The patient presented in the clinic with shortness of breath and wheezing. He indicated, “I have trouble breathing when I wake up in the morning. I can’t run around with my friends anymore because I can’t catch my breath and start wheezing a lot. That’s what happened the last time”

Subjective Data: Comment by priya: Missing chief complaint -1 Also the info under “subjective data “ is unnecessary because should be in hpi

History of Present Illness: 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.

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.

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

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

Objective: VS- BP= 115/70, R=18, T=97.8, P= 88, 02 Sat=91 (fluctuating) 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 Examination (PE)

HEENT: Pupils equal, round, reactive to light and accommodation

Extra-ocular movements intact.

Nose: Moist mucous membranes in oropharynx. increased secretion of the nasal, mucosal swelling, and nasal polyps

No cavities

Right ear: wax buildup; no edema, no erythema.

Left ear: wax buildup; no edema, no erythema.

Neck: No carotid bruits; hyperexpansion of the thorax

Lymph: No axillary, cervical, supraclavicular, pre-auricular, submental, or occipital lymphadenopathy.

Cardiovascular: no irregular heartbeats; a 12-lead electrocardiogram with diffuse, non-specific; ST-segment elevations noted.

Lungs: Respiratory distress, wheezes noted in all quadrants during both unforced breathing and forced exhalation (Nunes et al., 2017). No evidence of cyanosis. No egophony. Palpation revealed minor tenderness.

Chest: hyperexpansion of the thorax, appearance of hunched shoulders as well as chest deformity

Abdomen: Abdomen is soft, flat, no tenderness noted. No hepatosplenomegaly.

Skin: warm, minor perspiration noted; no discoloration, no rash.

Extremities: 2+ pulses in upper and lower extremities. No pain in toes or fingers. No edema or redness noted in any extremities.

Rectal: no sign of bleeding or trauma

Cranial nerves 2-12 grossly intact. 5/5 strength in all extremities bilaterally. Sensation intact in all extremities. Normal gait. 1+ DTR’s in biceps, triceps, supinator, knee, ankle. No clonus

.Psych: Appropriate affect; Signs of anxiety noted.

. The patient has rough dark patchy rashes in both arm pits. Right patchy rash is crusty.

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.

Differential Diagnoses

Chronic Asthma- Symptoms include wheezing, shortness of breath upon exertion/during exercise. These symptoms recur when airflow is obstructed as with this patient. The patient has a history of asthma and is currently taking asthma medication. The information provided by the parent, the description of the attacks by the child, and medication taken by the child in the pass are evidence of chronic asthma as suggested by Ullmann, 2018). This is the likely diagnosis.

Chronic Obstructive Pulmonary Disease-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 (Kopsaftis, Wood-Baker, & Poole, 2018). This patient did not complain or cough nor did he produce any mucous. This is not the likely diagnosis given the symptoms.

Panic Disorder: 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. This diagnosis is unlikely because it does not explain the wheezing nor was there any psychological signs that the patient suffered from anxiety issues in the past. The incidents described by the patient did not indicate the patient was under any anxiety or stress at the time (Craske & Stein, 2016).

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 (Rees, Singh, & Taylor, 2019). Previously, the patient was diagnosed with Asthma, which has since not been controlled.

Plan: The diagnostic plan for the patient should be unique and distinctive. That is, it should be based on his medical history, information from his parents, and the execution of a physical exam (American Association of Respiratory Care, 2018). 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

American Association of Respiratory Care (2018). Asthma action plan enhance patient care. Retrieved from https://www.aarc.org/nn18-patient-asthma-action-plans/.

Craske MG, Stein MB (December 2016). Anxiety. Lancet. 388(10063): 3048–3059. doi:10.1016/S0140-6736(16)30381-6. PMID 27349358.

Kopsaftis Z, Wood-Baker R, Poole P (June 2018). Influenza vaccine for chronic obstructive pulmonary disease (COPD) .The Cochrane Database of Systematic Reviews. 6: CD002733. 

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.

Rees, K; Singh, SJ; Taylor, RS (January 2019). Exercise-based cardiac rehabilitation for adults with heart failure". The Cochrane Database of Systematic Reviews. 1: CD003331

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.

Ullmann, N., Mirra, V., Di Marco, A., Pavone, M., Porcaro, F., Negro, V., Onofri, A., & Cutrera, R. (2018). Asthma: Differential Diagnosis and Comorbidities. Frontiers in pediatrics, 6, 276. https://doi.org/10.3389/fped.2018.00276

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