Episodic/Focused SOAP Note Assignment Discussion

Episodic/Focused SOAP Note Assignment Discussion

Patient Information:

1. J., 10-years old, African American, female

S.

CC (chief complaint): Severely underweight

HPI: 10-year-old African American female child in 3^rd grade who was referred to the clinic for being severely underweight. The mother reports that the child has had challenges eating with notable poor appetite but denies other symptoms such as generalized body swelling, nausea, abdominal pains, diarrhea, drenching night sweats, or severe weight loss. The patient’s poor appetite notably increased after the child visited with the father during the weekends. The mother reports that nothing seems to work to alleviate the symptoms and that poor weight gain has been present for the past year. Episodic/Focused SOAP Note Assignment Discussion

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Current Medications: The child is not taking any medications.

Allergies: No known food, drug, or environmental allergy.

PMHx: No major medical or surgical admissions or treatments have been received. She has no prevailing medical or surgical condition. She is current on his immunizations, including annual flu vaccines.

Soc Hx: The child comes from a single mother-led family. She lives with her mother on weekdays and her father on weekends. The father is notably also underweight and unemployed with alcohol use disorder. The mother works two jobs to cater to their family’s needs and reports that getting three meals a day is sometimes a big challenge. They live in a rented house with asbestos fitting and no smoke detectors. The mother has no car and seldom uses seat belts on the bus to work. Their living environment is in an impoverished neighborhood that is noted to have insecurity issues.

Fam Hx: There are no known familial illnesses. Both maternal and paternal grandparents are alive and well. The child is an only child to first-time parents and has no siblings. Episodic/Focused SOAP Note Assignment Discussion

ROS:

GENERAL: Reports notable weight loss in the past year but denies general body swelling, night swears, fever, fatigue, chills, and weakness.

HEENT:  Eyes: Denies eye discharge, poor night vision, blurred or double vision, or yellow discoloration of the sclera, and. Ears, Nose, Throat: Denies ear discharge, hearing loss, congestion, sneezing, runny nose, or sore throat.

SKIN: Reports brownish discoloration of body hair, which is easily plucked, especially from the scalp. Reports sagging skin, especially in the upper arms, but denies rash and itchiness.

CARDIOVASCULAR:  Denies chest pressure, pain, or discomfort, palpitations, or lower limb edema.

RESPIRATORY:  Denies cough, chest pain, and difficulty in breathing or shortness of breath.

GASTROINTESTINAL: Reports poor appetite but denies abdominal pain or discomfort, bloating, nausea, vomiting, diarrhea, or blood in the stool.

GENITOURINARY: Reports normal micturition habits with no burning sensation or blood in urine.

NEUROLOGICAL:  Denies headache, seizures, dizziness, or fainting episodes.

MUSCULOSKELETAL:  Denies muscle aches, joint pain, stiffness, or back pain.

HEMATOLOGIC: Denies easy bruising, anemia, or bleeding.

LYMPHATICS: Denies history of enlarged or removal of the spleen or lymph nodes.

PSYCHIATRIC: Reports evident withdrawal and social isolation but denies a history of anxiety, depression, or conduct disorders.

ENDOCRINOLOGIC: Denies heat or cold intolerance and excessive sweating, eating, or urination. Episodic/Focused SOAP Note Assignment Discussion

ALLERGIES: Denies history of eczema, rhinitis, or asthma.

O.

Physical exam:

GENERAL: The patient is notably small for age with prominent zygomatic bone and thin, brown, and bristle hair.

HEENT: Normocephalic. Eyes: Normal appearing eyelids, the palpebral conjunctiva is pink, and the bulbous conjunctiva is white with brownish spots. The anterior chamber is deep, the cornea is clear, the iris is dark brown, and the pupil is equal and reactive to light and accommodation. Ear: The pinna has no deformity and is not low-lying. The external meatus is clear, and the tympanic membrane is pink with a notable lustier cone of light. Note: Normal appearance, no nasal septum deviation, the nasal canal is clear and pink, with no mucus plugs. Throat: Pink with no enlarged tonsils.

SKIN: Dry and sagging skin in the upper extremities. Delayed return of skin turgor, capillary refill time is 4 seconds, and the mucus membranes are dry and cracking.

CARDIOVASCULAR: Normoactive precordium. No heaves, thrills, or taps. Palpable apex beat at the fifth intercostal line mid-clavicular—S1 and S2 heart sound heart. No murmur. No edema.

RESPIRATORY: Symmetrical chest wall with prominent ribs. No masses or scars. The percussion note is resonant. Vesicular breath sounds with good air entry were noted in all lung fields. Episodic/Focused SOAP Note Assignment Discussion

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GASTROINTESTINAL: The abdomen is non-distended, moving with respiration with a flat umbilicus. There are no masses or scars. The abdomen is soft on palpation, and there is no hepato-splenomegaly. The percussion note is tympanic. Bowel sounds are present in all quadrants.

GENITOURINARY: Ruptured hymen with lacerations on the introitus. No vaginal discharge or bleeding.

NEUROLOGICAL: Alert and oriented to time, place, and person. Cranial nerves are intact. No neck stiffness or tenderness. Motor exams reveal power 5/5, normal bulk, tone, and reflexes in all limbs.

MUSCULOSKELETAL: No deformities, joint pains, or stiffness, and normal ROM in all joints.

Diagnostic results: Adequate nutritional assessment with detailed dietary history and anthropometric assessments, including the patient’s weight, height, and mid-upper arm circumference, using appropriate World Health Organization (WHO) standard growth charts (Dipasquale et al., 2020). Complete blood count to assess for anemia, presence of an infection, and platelet count. Screen for sexually transmitted diseases, including HIV, on suspicion of sexual assault and the background of an underweight father. Episodic/Focused SOAP Note Assignment Discussion

A.

Differential Diagnoses.

1. Severe acute malnutrition. The child is notably small for her age and severely underweight. She has a poor appetite and sagging skin, with brown, thin, and bristle hair. Her skin turgor is delayed, and capillary refill time is prolonged, indicating dehydration. She also faces food insecurity as the mother is unable to provide three meals daily. The patient could be experiencing primary acute malnutrition, which is often caused by household food insecurity, poverty, and poor quality living environments, which are determinants of health that are present in the patient (Dipasquale et al., 2020). The primary belief about primary acute malnutrition is that it is mostly social rather than biomedical (Dipasquale et al., 2020). Therefore, the child fits the profile for primary acute malnutrition.
2. Child abuse – Sexual Assault. The child is notably anorexic following her weekend stays with her father, who has an alcohol abuse disorder. Also, on examination, she has a ruptured hymen with lacerations at various stages of healing in her vaginal opening. The typical symptoms of child sexual abuse include sadness, withdrawal, irritability, enuresis in a child who was previously toilet trained, and refusal to undress or unwillingness to be examined by a healthcare professional (Hanson & Wallis, 2018). The absence of injuries in the genital tract, such as vaginal lacerations, does not eliminate the occurrence of sexual abuse, given the rapid healing time of the genital epithelium (Hanson & Wallis, 2018). Therefore, a high index of suspicion is required to screen for sexual assault in pediatric populations.
3. Childhood depression. The child has a poor appetite with severe weight loss and appears withdrawn after the weekend visits with her father. Some of the contributing factors to depression in children include poor health, parental depression, and occurrences of traumatic childhood experiences such as child maltreatment or abuse (Dong et al., 2023). Therefore, depression and suicide assessment is required as part of an assessment for the child.
4. Eating disorder. The child is notably anorexic with severe weight loss and socially withdrawn. However, no episodes of binge eating or vomiting after eating are noted.
5. Oromotor dysfunction. This neuromuscular disorder affects oral muscle strength and tone, resulting in eating too little food. The disease is ruled out by normal muscle function in the child. Episodic/Focused SOAP Note Assignment Discussion

Discussion

To further assess the child’s weight-related health, I would require a detailed dietary history and anthropometric measurements, including weight and height, to compare their growth with WHO-accredited growth charts. The child is at risk of malnutrition, given the family history of household food insecurity, and at risk of child abuse while living with the father on the weekend, who has an alcohol use disorder. Therefore, I would require information regarding the history of abuse and food sources that the family uses often. Therefore, the three specific questions that I would ask about the child to gather more information are: Episodic/Focused SOAP Note Assignment Discussion

1. Can you describe your typical diet at home for the past week? What did you eat for each meal during the day?
2. Is the child visiting or staying with the father supervised?
3. Has the child ever complained of his father “hurting” her in any way, or have you noticed any behavioral changes in the child?

Finally, the strategies I could employ to encourage the parents to be proactive about their child’s health and weight include providing adequate health education on the child’s nutritional and emotional needs while offering suggestions on what the mother could do to engage the child more and improve their feeding habits. Lastly, I would encourage the mother to set up a balanced diet diary using more affordable food options to ensure she can provide at least three meals to the child daily. Alternatively, I could link her with social services to receive food stamps that would make meals much more affordable and available for the family. Episodic/Focused SOAP Note Assignment Discussion

References

Dipasquale, V., Cucinotta, U., & Romano, C. (2020). Acute malnutrition in children: Pathophysiology, clinical effects and treatment. Nutrients, 12(8), 2413. https://doi.org/10.3390%2Fnu12082413

Dong, Y., He, X., Ye, L., Sun, L., Li, J., Xu, J., Cui, Y., Li, Z., Hu, L., & Bai, G. (2023). Determinants of depression, problem behavior, and cognitive level of adolescents in China: Findings from a national, population-based cross-sectional study. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1159739

Hanson, F. R., & Wallis, E. (2018). Treating victims of child sexual abuse. The American Journal of Psychiatry, 175(11), 1064–1070. https://doi.org/10.1176/appi.ajp.2018.18050578 Episodic/Focused SOAP Note Assignment Discussion

                                                   CASE STUDY

 10 year old severely underweight male in 3nd grade who lives with her normal weight mom on the weekends and her underweight father during the weekend.

Include the following:

• An explanation of the health issues and risks that are relevant to the child you were assigned.
• Describe additional information you would need in order to further assess his or her weight-related health.
• Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
• Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
• Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.

 INSTRUCTIONS:

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

 REQUIRED READING/WEEKLY RESOURCES

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach(10th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 7, “Mental Status”
    This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
  • Chapter 23, “Neurologic System”
    The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care(6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Episodic/Focused SOAP Note Assignment Discussion
  • Chapter 4, “Affective Changes” Download Chapter 4, “Affective Changes”
    This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.
  • Chapter 9, “Confusion in Older Adults” Download Chapter 9, “Confusion in Older Adults”
    This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.
  • Chapter 13, “Dizziness” Download Chapter 13, “Dizziness”
    Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.
  • Chapter 19, “Headache” Download Chapter 19, “Headache”
    The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.
  • Chapter 31, “Sleep Problems” Download Chapter 31, “Sleep Problems”
    In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis. Episodic/Focused SOAP Note Assignment Discussion
• Sullivan, D. D. (2019). Guide to clinical documentation(3rd ed.). Philadelphia, PA: F. A. Davis.
  • Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
• O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression.Links to an external site.Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

• Shadow Health. (2021). Welcome to your introduction to Shadow Health.Links to an external site.https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help desk.Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
• Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)Download DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
  Use this template to complete your Assignment 3 for this week. Episodic/Focused SOAP Note Assignment Discussion

NOTE BELOW:

I WILL UPLOAD THE EPISODIC/FOCUSSED NOTE TEMPLATE FOR WEEK FIVE

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Episodic/Focused SOAP Note Assignment Discussion

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching. Episodic/Focused SOAP Note Assignment Discussion

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis. Episodic/Focused SOAP Note Assignment Discussion

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting. Episodic/Focused SOAP Note Assignment Discussion