soap note 6

STUDENT NAME

DATE OF ASSIGNMENT: 07/06/2020

Patient Initials: C.W

Date of Encounter: 06/29/2020

Sex: Male

Age/DOB/Place of Birth: 6y/o, DOB: 02/27/2013, Miami, FL

SUBJECTIVE

Historian: Patient’s Father, and Patient C.W.

Present Concerns/CC: “Pains in the tummy”

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

Sports/physical activity; Developmental Hx)

The patient is not sexually active. He will begin the first grade soon. The patient spends some of his time playing with his parents or at his pool in the homestead. He also visit his grandma at her house and spend some time with her. He spends most of his time watching television and YouTube videos in the living room.

HPI: (must include all components - OLD CARTS)

The patient’s tummy started aching 3 days ago. He is currently experiencing diarrhea after every meal. He wakes up frequently in the middle of the night to go to the washroom. His diarrhea is watery. It is about 5 or 6 diarrheas per day. The diarrhea has no mucus or blood. His father also has similar symptoms. They resolved this week. His tummy pain is not alleviating. Food seems to exacerbate the pain. The patient rates the pain at 8 out of 10. His father rates it as 6 out of 10. It is all over the abdominal region including all quadrants. Father says he has no chills, fever or headaches.

Medications: (List with reason for meds)

The patient is not taking any medication at the moment.

PMH:

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

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: All vaccines are updated.

Family History (please identify all immediate family)

Mother: She is 28 years old with no health problem

Father: He is 31 years with no health problems

The patient has no siblings

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

He will soon be an elementary school student. The patient lives with parents and has no siblings. The patient has no exposure to tobacco, alcohol or any other drugs. He is also not exposed to guns in their house. When travelling, he uses their family car and sits in the rear seat and wears safety belt. The patient has no evidence of child abuse.

Review of Systems (ROS)

General

The patient is positive for nausea. He denies chills, fever and vomiting.

Cardiovascular

The patient denies palpitations, pressure or chest pains.

Skin

The patient denies itching, redness or lesions.

Respiratory

The patient denies cough, difficulty breathing and shortness of breath.

Eyes

The patient denies visual loss, blurred vision or double vision.

Gastrointestinal

The patient is positive for abdominal pain and nausea. He is also positive for diarrhea. He denies vomiting.

Ears

The patient denies hearing loss, drainage or pain.

Genitourinary

The patient denies painful and frequent urination.

Nose/Mouth/Throat

The patient denies difficulty swallowing, throat pain, mouth pain, discharge and congestion.

Musculoskeletal

The patient denies pain and limited range of movement.

Breast

Not Applicable (N/A)

Neurological

The patient denies dizziness, headache, paralysis, syncope and ataxia.

Heme/Lymph/Endo

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

Psychiatric

The patient denies depression, anxiety, insomnia or mood swings.

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

Attach growth chart

Weight 43 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

The patient is well-groomed with no distress. He was accompanied by his father today. Their interaction is normal with no signs of fear or abuse. However, the patient looks tired.

Skin

The skin around the patient’s eyes, mouth and nose is normal for his age. He has no bruises, clubbing or cyanosis. The patient does not show any sign of dehydration. His skin turgor is normal.

HEENT

The patient’s head is atraumatic and normocephalic. His eyes are PERRLA with no scleral or conjunctival infection. His ears are bilateral and pearly grey with some positive light reflex. The neck is full ROM and supple. His throat is non-inflammatory and visibly pink. His mouth is moist and oral mucosa pink. The patient has gag reflex but no dental caries.

Cardiovascular

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

Respiratory

The patient’s lungs are clear to auscultation bilaterally, posteriorly and anteriorly. He has normal respiratory effort. His lungs has no wheezing, no Ronchi and no rales.

Gastrointestinal

He is painful, soft and tender to deep palpation. All the four quadrants are palpated. The quadrants provoke pain when they are palpated. The four quadrants has bowel sound with no masses. He has no hepatomegaly, no ascites, no splenomegaly, no guarding and no rebound.

Breast

Not Applicable (N/A)

Genitourinary

The external genitalia evaluation deferred. He has no CVA tenderness.

Musculoskeletal

The patient has normal ROM and gait with no deformities, no rigidity and no atrophy.

Neurological

The patient has normal tone with no local findings.

Psychiatric

The patient has no depression, anxiety or 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 asked, the patient’s father says that his son has no signs of public hair. This is a pre-pubescent child characteristic at Tanner stage 1 (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

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

E- The patient will begin 1st grade during fall.

A- The patient watches YouTube videos and TV all day. He used to play dates with his friend. They would play with the Legos.

D- His father says that he has never contacted drugs or being around any person with any kinds of drugs.

S- N/A.

S- N/A

Differentials Diagnostics and Primary

1) General abdominal pain (R10.84). The patient is experiencing general abdominal pain. The pain is rated 6 out of 10 with no specific location in his abdomen. The region is painful when it is palpated.

2) Unspecified viral intestinal infection (A08.4). The patient shows characteristic signs of a stomach flu or virus. He experiences diarrhea with or with no nausea and abdominal pain (Hartman et. Al., 2019). The patient’s father most likely had the same viral infection a week ago. He may have transmitted it to his son.

3) Unspecified appendicitis (K37). This is not likely since the patient’s pain is not localized to his right lower quadrant. Appendicitis may occur at any age. However, it commonly occur between 10 and 19 years of age. In addition, the patient shows no clinical signs to point this diagnosis (Snyder et al., 2018).

Treatment:

The treatment of this patient is simple and straightforward. However it have to be followed by the patient himself and parent for the best outcomes. If the diagnosis is viral gastroenteritis, the patient have to be sufficiently hydrated. The patient is having diarrhea and is losing a lot of body fluids. He is not experiencing vomiting or any sign of dehydration. This does not imply that he is clear. Children of ages between 2 and 10 years should get 100 to 200 ml of fluid daily. The fluids may be water or juices. However, the patient should avoid high acidity fluids such as citrus juices or sodas. Apple juice is awesome and liked by children. However, the essential fluid is water. The patient should take the fluid after every meal especially after he diarrhea. The virus may get out with time. However, if his condition deteriorates, he should be taken to a medical facility for further assessment and treatment. In addition, it is essential to maintain good hygiene and wash hands regularly to prevent further infections (Viral gastroenteritis, 2018). The patient’s parents should also disinfect commonly used surfaces to kill any virus on the surfaces. The patient should stay indoors until the symptoms of the viral infection disappears. This prevents infection with bacteria and other viruses as he is currently compromised

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