week 6

STUDENT NAME

DATE OF ASSIGNMENT: 06/06/2020

Patient Initials: S.L

Date of Encounter: 06/03/2020

Sex: Male

Age/DOB/Place of Birth: 6y/o, DOB: 01/17/2014, Miami, FL

SUBJECTIVE

Historian: Patient’s Father, and Patient S.L.

Present Concerns/CC: “My tummy hurts a lot”

Reason given by the patient for seeking medical care “in quotes”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;

Sports/physical activity; Developmental Hx)

Patient is sexually inactive, will start 1st grade soon. He spends some of his time as his pool in the backyard or playing with his mom and dad. Sometimes he goes to his grandma’s house and spends some time with her. Otherwise, most of his time is spent watching TV and YouTube videos in the living room.

HPI: (must include all components - OLD CARTS)

Patient’s stomach began to hurt 3 days ago. His is experiencing diarrhea after all meals. He frequently wakes up in the middle of the night to go to the bathroom. The diarrhea is runny and watery, about 4 or 5 diarrheas per day, with no blood or mucus. Patient’s father experienced the same symptoms, but they resolved last week. There are no factors that alleviate his pain, and food seems to exacerbate it. The pain is described by the patient as an 8 out of 10, but his father says it’s more like 6. It is located throughout his abdominal region encompassing all quadrants. Father denies fever, chills or headaches.

Medications: (List with reason for meds)

Patient not currently taking any medication.

PMH:

Allergies: Several grass types, dust, pollen (Mild allergies)

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

None

Hospitalizations/Surgeries:

None

Immunizations: All vaccines up to date.

Family History (please identify all immediate family)

Mother: 28 years old, no current health problems

Father: 30 years old, no current health problems

No siblings

Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)

Soon to be elementary school student. Lives with his parents, and no siblings. Is not exposed to alcohol, tobacco, or any drugs. Is not exposed to guns in the house. Travels in the rear car seat, wearing the seatbelt. No evidence of domestic child abuse.

Review of Systems (ROS)

General

Positive for nausea. Denies fevers, chills, and vomiting.

Cardiovascular

Denies chest pain, pressure, palpitations

Skin

Denies lesions, itching, or redness.

Respiratory

Denies shortness of breath, denies cough, denies difficulty breathing.

Eyes

Denies blurred vision, denies visual loss, denies double vision.

Gastrointestinal

Positive for nausea and abdominal pain. Positive for diarrhea. Denies vomiting.

Ears

Denies hearing loss, pain, or drainage.

Genitourinary/Gynecological

Denies painful urination, denies increased frequency.

Nose/Mouth/Throat

Denies throat pain. Denies difficulty swallowing Denies congestion, denies discharge, denies mouth pain.

Musculoskeletal

Denies pain, denies limited range of movement.

Breast

N/A

Neurological

Denies headache or dizziness, denies syncope, paralysis, or ataxia.

Heme/Lymph/Endo

Denies anemia, bleeding or bruising, denies enlarged nodes. Denies change in temperature sensitivity.

Psychiatric

Denies anxiety, or depression. Denies mood swings, denies insomnia.

OBJECTIVE (plot height/weight/head circumference along with noting percentiles)

Attach growth chart

Weight 42 lbs.

Around 25th percentile

Temp 98.7 F

BP 114/76 mm/hg

Height 44 inches, 3’8”

Around 25th percentile

BMI: 15.3

Growth chart at bottom of SOAP Note

Pulse 78 bpm

Resp 16/min

OBJECTIVE (Physical Examination)

General Appearance and parent-child interaction

Patient looks well groomed, and in no obvious distress. He came with his father today and their interaction seems normal, there are no signs of abuse or fear. Patient looks tired.

Skin

Skin around the nose, eyes, and mouth is normal for age. No cyanosis, clubbing or bruises. No signs of dehydration. Skin turgor normal.

HEENT

Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TM’s pearly grey with positive light reflex. Neck: supple, full ROM. Mouth/Throat: Throat is visibly pink, and non-inflammatory. Oral mucosa pink and moist, no dental caries, gag reflex present.

Cardiovascular

S1, S2 heard, normal rate, normal rhythm, 2 sec capillary refills, no murmurs, no gallops, no palpation, no edema.

Respiratory

Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no Ronchi, no wheezing.

Gastrointestinal

Soft, tender and painful to deep palpation. All 4 quadrants palpated; all quadrants provoke pain when palpated. No masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding.

Breast

N/A

Genitourinary

No CVA tenderness. External genitalia assessment deferred.

Musculoskeletal

Normal gait and ROM. No rigidity, no deformities. No atrophy.

Neurological

Normal tone, no local findings.

Psychiatric

No depression or anxiety, no insomnia.

In-house Lab Tests – document tests (results or pending)

None

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)

Tanner Stage 1. When the father is asked, he states that the patient has no signs of pubic hair. This is characteristic of a pre-pubescent child at Tanner stage 1. (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

H- Lives with his parents in Miami, FL. Has lived at their current house for 6 years. Has a pet cat. The patient feels safe at home and in his neighborhood. There are no weapons at home

E- Will start 1st grade in the fall.

A- Watches TV and YouTube videos all day. Used to have play dates with his best friend, and they would play with Legos.

D- Patients father states that he has never been in contact with or ever experienced being around anyone with drugs of any kind.

S- N/A.

S- N/A

ASSESSMENT (Diagnosis – 3 Differentials and Primary)

· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

· Primary diagnosis

· Is #1 on list of differentials

· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

1) Generalized abdominal pain (R10.84) This is what the patient is experiencing. Pain on a scale 6 out of 10 with no localized location in the abdominal region. This region is painful when palpated.

2) Viral intestinal infection, unspecified (A08.4) The patient has the characteristics signs of a stomach virus, or a stomach flu. He has diarrhea with or without nausea and vomiting or abdominal pain (Hartman et.al., 2019). His father likely had the same viral infection one week ago and transmitted it to his son.

3) Unspecified appendicitis (K37) This diagnosis is not very likely considering the pain is not localized to the patient’s right lower quadrant. Appendicitis can occur at any age, but it most commonly occurs between ages 10 and 19 (Snyder, Guthrie, & Cagle, 2018). Additionally, there are no clinical signs that may point to this diagnosis.

PLAN including education

PLAN including education

· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

· Include EB rationale for all aspects of your treatment plan:

· Vaccines administered this visit

· Vaccine administration forms given

· Medication-amounts and mg/kg for medications

· Laboratory tests ordered

· Diagnostic tests ordered

· Patient education including preventive care and anticipatory guidance 9 Non-medication treatments Follow-up appointment with detailed plan of f/u

Treatment:

The treatment for this patient is straightforward and simple but must be followed by both the patient and his parents for the best results. With a diagnosis of viral gastroenteritis, the patient must be adequately hydrated. He is experiencing diarrhea and losing a lot of fluids. The patient is not vomiting, and no signs of dehydration were found today but this does not mean he is clear. Children that are 2 to 10 years old should receive 100 to 200mL of fluid per day (Hartman et.al., 2019). He should be drinking anything like water or juices but should stay away from high acidity drinks such as sodas and citrus juices. Apple juice is great, and is liked by many children, but the most important liquid is water. Make sure he is drinking after every meal, and especially after any episodes of diarrhea. The virus will most likely pass with time, but if his condition worsens, take him to a hospital for further evaluation and treatment. Additionally, it is very important to keep clean hygiene and wash your hands daily to prevent a future infection (Viral gastroenteritis, 2018). Disinfect commonly used surfaces in the house to kill off any virus on them. Do not go outside until the virus symptoms have disappeared, to prevent infection with other viruses and bacteria, as the patient is compromised at the moment.

References

Emmanuel, M., & Bokor, B. R. (2019, May 13). Tanner Stages. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470280/

Hartman, S., Brown, E., Loomis, E., & Russell, H. A. (2019). Gastroenteritis in Children. American Family Physician,99(3), 159-165.

Katzenellenbogen, R. (n.d.). HEADSS: The "Review of Systems" for Adolescents. Retrieved May 3, 2020, from https://journalofethics.ama-assn.org/article/headss-review-systems-adolescents/2005-03

Snyder, M. J., Guthrie, M., & Cagle, S. (2018). Acute Appendicitis: Efficient Diagnosis and Management. American Family Physician, 98(1), 25-33.

Viral gastroenteritis (stomach flu). (2018, October 16). Retrieved June 05, 2020, from https://www.mayoclinic.org/diseases-conditions/viral-gastroenteritis/symptoms-causes/syc-20378847