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Case Study For Wellness Of A Child SOAP NOTE Assignment

Case Study For Wellness Of A Child SOAP NOTE Assignment

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SUBJECTIVE

Client’s Initials: J.D         Age: 5 years      Race: Caucasian      Gender: Male       Date of birth: 04/12/2018    Insurance: Yes

Chief Complaint (CC): Vomiting and diarrhea for two days

HPI: J.D. is a 5-year-old Caucasian male child brought into the office by his mother with complaints of diarrhea and vomiting for two days. The mother reports that the symptoms began yesterday morning and started with him vomiting. The vomiting was of sudden onset, post-prandial, and non-projectile. The vomit content is white and contains digested food. He had about four episodes that day but has only had one episode today. The diarrhea is watery and mucoid, with whitish mucus but not excessively foul smelling and no bloodstains. He had many episodes since the onset and has had two episodes this morning. There is no associated fever but he complains of some abdominal cramps and general body weakness. The abdominal pains are on and off, with a severity of 3/10. It is slightly relieved by emptying the bowels and lying down. She has not given him any medications to help with the symptoms. There is no recent history of travels but several children from his class have had similar symptoms. His older brother, 10 years old, does not have any symptoms. There is no loss of appetite, he is tolerating foods and drinks well. Case Study For Wellness Of A Child SOAP NOTE Assignment

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BIRTH HISTORY

Antenatal History: The mother attended six antenatal clinic visits during her pregnancy, from 6 weeks gestation. She received all the recommended antenatal interventions including iron and folic acid and tetanus/diphtheria shots. There were no complications during the pregnancy period.

Natal hx: The baby was born at 38 weeks gestation via spontaneous vertex delivery. He cried immediately after birth, and no resuscitation was done. He weighed 3.9kg.

Postnatal hx: He was breastfed within 24 hours after delivery, with no complications post-delivery

Nutritional History: Exclusive breastfeeding for 2 months then he was introduced to complimentary infant formula. He was started on soft foods at 6 months. He is currently eating the normal diet at home.

Immunization: He has received all the recommended childhood vaccinations attained per age.

Birth- Hep B vaccine, second dose at 2 months, At 2 months-  DTaP, Hi, IPV, PCV, Rotavirus, At 4 months- DTaP, Hib, IPV, PCV, RV, At 6 months- DTaP, Hib, PCV, Influenza, At 12 months- MMR, PCV, Varicella, At 4 years- DTaP, MMR, IPV, Varicella. He has also received his seasonal flu shot (last shot was 1 week ago)

Developmental history: He attained all the developmental milestones at an appropriate age; He sat without support at 6 months, walked at 11 months, and talked by age 1. He is currently in school and relates well with his peers and teachers. He has appropriate communication skills for his age.

Past Medical/Surgical History: He has no history of previous hospital admissions or surgeries. No known chronic medical illnesses.

Allergies: He has peanut allergies, exposure causes rash tongue swelling, and difficulty in breathing. No other known drug or environmental allergies.

Medications: Uses his regular Epipen for allergen exposure. No other medications

Family History: There is no known family history of chronic illnesses like diabetes or hypertension.

Social History: He is the second born of 2 siblings, both boys. They live in a 3-bedroom apartment with both parents. The father is a telephone engineer and the mom is a stay-at-home mother. He is an active child, plays sports at school, and participates in school dances. There is no history of cigarette smoke exposure in the home. He eats healthy home-cooked meals mostly. Our usual diet consists of cereal, eggs, and bacon for breakfast, lunch at school, and mashed potatoes/beef for dinner. Case Study For Wellness Of A Child SOAP NOTE Assignment

Review of Systems

Constitutional: He has general body malaise, no headaches or dizziness

Eyes: No eye pain, discharge, or swelling, no eye redness or itchiness

Ears/Nose/Mouth/Throat: No hearing difficulties, no ear pains, no nasal congestion, or discharge, no sore throat or pain with swallowing

Cardiovascular: He denies any easy fatigability or shortness of breath with physical activity

Pulmonary: No cough, wheezing, or difficulty in breathing

Gastrointestinal: Has abdominal cramping, vomiting, and diarrhea, no bloodstained stools

Genitourinary: No pain or difficulty with passing urine, no blood in urine, or any color changes

Musculoskeletal/Skin: He denies any joint pains, muscle aches, or skin rashes or lesions

Neurological: No headaches, loss of consciousness, or blurry vision

Endocrine: No excessive sweating or feeling of cold, no excessive thirst or hunger

Psychiatric: Denies any features of excessive hyperactivity or lack of attention to schoolwork

Hematologic/Lymphatic: Denies any easy bruising or bleeding, no swellings around the throat

Allergic/Immunologic: No recent exposure to peanuts, no allergic reactions

OBJECTIVE

Vital Signs: HR 100 /min, BP 102/88 mmHg, Temp: 37.6, RR: 20 breaths/min, SPO2 99% RA, Height 109 cm, Weight 20kg (BMI- 16.8, Normal) 84% percentile, which is a healthy weight for age.

Physical Exam

General exam: He is a young boy who appears to be in fair general condition and well-nourished. He is not in any obvious pain or respiratory distress. He has some dehydration- dry lips and mucous membranes, but is not pale, no jaundice, no lymphadenopathy, no edema.

No sunken eyes, skin pinch return is fast, no restlessness or irritability. This is classified as just some dehydration.

HEENT: The head is normocephalic with a normal hair distribution, no contusions, or bruises

Respiratory: The RR was 20 b/min with an SPO2 of 99% on room air. On inspection, there is bilateral chest wall expansion with respiration, and no visible masses, lesions, or therapeutic scars. No obvious chest wall deformities. On palpation, the trachea is central. On auscultation, there were vesicular breath sounds bilaterally, but no added sounds.

Cardiovascular: Peripheral pulses are good, no cyanosis, and the capillary refill is less than 1 second. Normoactive precordium, Apex beat felt at 4th intercostal space, midclavicular line. S1 S2 heard, no murmurs, rubs, or gallops

Abdomen: The abdomen is of normal fullness and moving with respiration, the umbilicus is inverted, no obvious masses or swelling around the umbilicus. No scars, lesions, or hypo/hyperpigmentation. On light palpation, it was warm to the touch, with no tenderness or masses. On deep palpation, there was no organomegaly or tenderness.  Bowel sounds active in all quadrants. Percussion was tympanic.

CNS: He is alert and oriented in time, place, and person. Cranial nerves II-XII are grossly intact. Pupils equal and reactive to light bilaterally. Normal power and bulk in all muscle groups, normal reflexes in all joints.

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ASSESSMENT

Differentials

  1. Acute viral gastroenteritis, A08.4– Acute GE is common in children and presents with diarrhea and vomiting, which may or may not be associated with fever, abdominal pains, and loss of appetite. The infection is fecal-oral through ingestion of the organisms in infected foods (Cai et al., 2023). It is mostly caused by viruses, rotavirus being the commonest cause but can also be bacterial or parasitic infection (Amodio et al., 2022). The organisms cause inflammation of the GIT causing the symptoms of diarrhea and vomiting, which can cause dehydration. This patient presented with the symptoms of diarrhea and vomiting associated with general malaise and dehydration. There is a positive history of similar symptoms occurring in other school children, making the diagnosis more likely (Rivera-Dominguez & Ward, 2023). The diarrhea was watery, mucoid, and non-bloody, supporting the diagnosis of a viral infection.
  2. Bacterial gastroenteritis, A09– It also presents with diarrhea, vomiting, and abdominal cramps. However, for a bacterial infection, the diarrhea would mostly be bloody and would be associated with high fevers as opposed to viral infections (Rivera-Dominguez & Ward, 2023)Case Study For Wellness Of A Child SOAP NOTE Assignment.

PLAN

Diagnostics:

Stools for microscopy, culture, and sensitivity may be used to rule out a bacterial infection.

UECs to rule out any electrolyte imbalances

A complete blood count may be done to rule out systemic infection and anemia

Treatment:

The treatment for viral gastroenteritis is mainly supportive management of the symptoms and dehydration. For children without severe dehydration, who can drink and eat, encourage them to drink plenty of fluids frequently for adequate hydration.

Education:

Educate the mother on preventive measures including hand and food hygiene. Teach the child to wash their hands after using the toilet and before eating

Ensure proper hygiene in storing and preparation of foods

Ensure that their children are vaccinated according to the recommended infant schedule, including rotavirus vaccine

Ensure adequate hydration by giving fluids frequently.

Watch out for signs of deterioration like the onset of severe dehydration like the development of sunken eyes, dry mouth, lethargy, and insufficient urination.

Follow-up: Advise the parent to return at any time if the symptoms of diarrhea and vomiting worsen or do not resolve within two weeks if they develop fever or poor oral intake.

References

Amodio, E., De Grazia, S., Genovese, D., Bonura, F., Filizzolo, C., Collura, A., Di Bernardo, F., & Giammanco, G. M. (2022). Clinical and epidemiologic features of viral gastroenteritis in hospitalized children: An 11-year surveillance in Palermo (Sicily). Viruses15(1), 41. https://doi.org/10.3390/v15010041

Cai, H., Shao, Y., & Yu, W. (2023). Prevalence and associated factors of acute gastroenteritis in children and adolescents aged from 6 to 17 years old: A cross-sectional study based on the national health and nutrition examination survey database 1999–2018. BMJ Open13(2), e068319. https://doi.org/10.1136/bmjopen-2022-068319

Rivera-Dominguez, G., & Ward, R. (2023, April 3). Pediatric gastroenteritis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK499939/ Case Study For Wellness Of A Child SOAP NOTE Assignment

Clinical Documentation Template

 Directions: Students may use this general SOAP note template or their own.  Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:

Documentation Guidelines – Reimbursement

Delete all text in red – these are instructions and not part of the SOAP document.

 

 

Student Name and clinical course: (If no title page): ______________________

 

ID:

Client’s Initials*:_______Age_____ Race__________Gender____________Date of Birth___________

Insurance _______________   Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client  confidentiality.  Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

 

Subjective:

 

 

CC: Patient’s own words, a few words, a sentence or less. Example: “cough and fever”

 

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

 

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms,  Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

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Past Medical History:

  • Medical problem list

 

  • Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)

 

  • Surgeries:

 

  • Hospitalizations:

 

  • LMP, pregnancy status, menopause, etc. for women

 

Allergies:

Food, drug, environmental

 

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

 

Family History:

 

Social History:

 

-Sexual history and contraception/protection (as applies to the case)

 

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

 

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

 

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.

 

 

Constitutional:

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

Objective

 

Vital Signs:   HR         BP       Temp               RR       SpO2           Pain

 

Height             Weight             BMI    (be sure to include percentiles for peds)

 

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

 

Physical Exam (write out by system):

 

Start with a general survey:

 

 

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

 

Differentials (with a brief rationale for each):

1.

2.

3.

 

Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)

 

Plan (4 pronged-plan for each problem on the problem list)

 

Diagnostics:

 

Treatment:

 

Education

 

Follow Up:

 

 

 

List plan under each Diagnosis.

Example

1: Hypertension (I10)

A: Lisinopril/HCT 20/12.5 Daily #90, refills 3

B: BMP in 6 months

C: Recheck BP in 2 Weeks

D: Low Sodium Diet and lifestyle modifications discussed

 

2: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

 

3: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

  1. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

  1. Return to clinic in 3-4 months to reassess

Case Study For Wellness Of A Child SOAP NOTE Assignment

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