Soap Notes For Pediatric Cases Assignment Paper

Soap Notes For Pediatric Cases Assignment Paper

I need 5 soap notes for pediatric cases. half page max each. not too detailed.cases can be the following : cough for 7 year old, sprained right ankle , regular physical for 15 year old male, vaccination appointment at 6 month, strep throat for 11 year old . please keeo the history and allergy and social part to a minimum. ROS should be ” negatvie except as stated per HPI”thank you Soap Notes For Pediatric Cases Assignment Paper

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SOAP Note: Immunization

Patient information

Patient initials: W.E     Age: 6-month-old         Gender: Male                           Race: Caucasian

S

CC: ‘Six-month vaccination appointment.’

HPI: W.E, a six-month old Caucasian boy was brought by his mother to the clinic for his six-month vaccination appointment. No fever, sore throat, or running nose were reported. His mother further denied any allergy to food or any kind of drug.

Current medication: Seven Seas 2,5ml PO QD

PMH: none

Allergy: NKDFA

Immunization: up-to-date and was brought for his six-month shots.

Family history: no significant family history reported.

Social history: The patient is the first born to his mother. They live in safe apartment. His mother reported not yet introduce him to solid food and that she reports to smokes more often but never around the child.

ROS

General: -ve fever, fatigue and loss of appetite, and weight loss.

HEENT: negative for loss of vision or hearing.

CV: -ve for chest pain

Resp: -ve for cough, and night sweats

GI/GU: -ve for N/V/D, dysuria and polyuria

MSK: -ve for muscle pain

Skin: -ve for skin rash

Endocrine: -ve for cold or heat intolerances

O

PE:

Vts: Temp 37.3 rectal P.78   RR: 20 SpO2 98% Wt. 17lb Ht. 66 cm head circumferences 40.2

General: he is well-developed, well-nourished and appear well hydrated.

HENT: normocephalic and atraumatic. EOMI. PERRLA (Jarvis,2018).

CVS: Quiet precordium, no thrills. RRR.

Respiration: symmetric chest expansion

Abdomen: soft and non-tender. Bowels sound normoactive.

Genitalia: circumcised. Bilateral descended testes.

Extremities: Warm, no clubbing. Good skin turgor.

Neurological: normal clonus in both feet. Normal Gallant reflexes

A:

Immunization

P.

Medication: Dtap, Hib and PCV13 shots to be administered to the child through IM (Tiley et al.,2018)Soap Notes For Pediatric Cases Assignment Paper.

Patient education: The mother should be advised to give her baby Calpol 100ml for pain at injection site. She should be advised accordingly on possible side effects such as fever.

Follow-up: Patient to be returned to clinic as needed

 

 

References

Tiley, K. S., White, J. M., Andrews, N., Ramsay, M., & Edelstein, M. (2018). Inequalities in childhood vaccination timing and completion in London. Vaccine, 36(45), 6726-6735.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

SOAP Note: Strep throat

Patient information

Patient initials: F.K      Age: 8-year-old         Gender: Male                           Race: Caucasian

S

CC: “Sore throat and fever”

HPI: F.K, a 7-year-old Caucasian boy presented to the clinic accompanied by his mother with a chief complaint of sore throat and fever which began 2 days ago. He was also reported to have throat pain which he rated 7/10. The patient stated that his throats pains when he tries swallow anything. His mother reported to have given him Calpol but this only gave minimal relief. Reported having general fatigue but denied issue with abdominal disorder.

Current medication: Calpol 200mg 10ml PO PRN

PMH: none

Surgical Hx: none reported

Allergy: NKDFA

Immunization: up-to-date. Last received flu vaccine 4/9/21

Allergy:

Family history: paternal grandmother (deceased): COPD. Paternal grandmother (69 y/o): hypertension: maternal grandmother (deceased): CKD

Social history: The patient is the fifth born in the family of 6, he is currently in Grade two at a nearby local school. Has never tried any illicit drugs. Lives with his parent in a safe neighborhood.  Eats healthy food and enjoy football match with his peers Soap Notes For Pediatric Cases Assignment Paper

ROS

General: +ve fever, fatigue and loss of appetite. -ve for weight loss.

HEENT: negative for loss of vision, hearing and instances of nosebleed. +ve for throat pain.

CV: -ve for chest pain

Resp: +ve for cough. -ve for night sweats

GI/GU: -ve for N/V/D, dysuria and polyuria

MSK: -ve for muscle pain or weaknesses

Skin: -ve for skin redness or skin rash

Endocrine: -ve for cold or heat intolerances

Allergy/immunologic: -ve for Asthma, Rhinitis, and sensitivity to latex.

Neuro: -ve memory loss and syncope.

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O

PE:

Vts: Temp 38.6 P.82   RR: 20 BP:  94/112 SpO2 98% Wt. 50lb Ht. 121.3cm

General: he is well-developed, and well-nourished. Appear well hydrated.

HENT: normocephalic and atraumatic. Tiny red spot on the roof of mouth noted. Throat is red and swollen tonsil noted.

CVS: Quiet precordium, no thrills. Normal S1 and S2. No murmur or gallops (Jarvis et al.,2019).

Respiration: symmetric chest expansion. Clear lung sound noted.

Abdomen: soft and non-tender. Bowels sound normoactive.

Extremities: Warm, no cyanosis or edema. Good skin turgor.

Neurological: negative Brudzinski and Kernig signs

Psych: -ve

A:

Lab test

CBC: result pending

Throat culture: result pending

Rapid strep test: positive

Diagnosis

Differential diagnoses

1. Strep throat
2. Viral pharyngitis
3. Mononucleosis

Primary diagnoses: Strep throat

P.

Medication: give Amoxil 200ml 10ml PO bid x3 (de Cassan et al.,2020).

Patient education: the patient must adhere to prescription to avoid development antibiotic resistance.

Follow-up: if no improvement is noted, the patient to be returned to the clinic for further intervention.

References

Jarvis, C., Browne, A., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2019). Physical examination and health assessment (3rd Canadian ed.).

de Cassan, S., Thompson, M. J., Perera, R., Glasziou, P. P., Del Mar, C. B., Heneghan, C. J., & Hayward, G. (2020). Corticosteroids as standalone or add‐on treatment for sore throat. Cochrane Database of Systematic Reviews, (5). Soap Notes For Pediatric Cases Assignment Paper

SOAP note: Chronic cough

Patient information

Patient initial: W.G.     Age: 7.       Sex: male      Race: African-American

CC: ‘Persistent Cough For 7 Days.’

HPI: W.G, a 7-year-old African-American boy presented to the clinic accompanied by his mother with a chief complain of persistent cough for period of 7 days now. He also reported running nose, right ear pressure and chest tightness. The mother reported the symptoms to worsens in the night disrupting the patient sleep. She reported having seek Benadryl syrup to help her son with cough but this only gave a minimal relief. Denies nausea, vomiting and diarrhea.

Medication: Benadryl 200mg 10ml PO nocte

Allergy: he is allergic to pollen

PMHx: no past medical/surgical history reported.

Immunization: up-to-date.

Family history: no significant family history reported

Social history: The patient is currently in grade 2 in a nearby school. He lives in a safe neighborhood. Has never attempted taken any illicit drug. His parent is financially stable and he is covered under insurance. Enjoy playing football once in a while with his peers. Eats a well-balanced diet.

ROS: Soap Notes For Pediatric Cases Assignment Paper

General: denies fever, chills, and changes in weight. Reported general fatigue and wheezing

HEENT: denies visual disturbances. Reported fullness in his right ear.

CV: + chest tightness. Denies irregular heart beat

GI: denies nausea, vomiting and diarrhea.

GU: denies dysuria and polyuria

Msk: denies muscle pain.

Respiratory: reported persistent cough which worsens in the night. Denies SOB.

Skin and breast: no skin rashes or bruising reported.

Neurological: denies cold or heat intolerances

O

PE:

Vts: T 37.1, HR 72, RR 20, BP 93/60, SpO2 100% Wt. 66 lb. Ht. 4’5

General: Well hydrated and appears stated age.

Skin: no rashes or bruises noted.

HEENT: normocephalic, clear nasal discharge noted.

CV: RRR, no murmur or galops

Msk: symmetrical with ROM intact.

Resp: no cyanosis. Clear lung sound.

Neurological: balanced gait. Speech clear.

Psychiatric: oriented to place and time (Forbes et al.,2020). Short term and long-term memory intact.

A.

Lab test and result

CBC: result pending

Lung functional test: result pending

Allergy skin test

Diagnoses

Differential diagnoses

1. Childhood asthma

This condition is distinguished by a chronic cough that worsens at night or with physical exertion (Dharmage et al.,2019). It also presents with pressure in the right ear, chest tightness, and weariness, as seen in the case presentation. Thus, the most likely diagnosis

Other diagnoses

1. Viral rhinitis
2. Chronic allergies

Primary diagnoses: childhood asthma

P

Medication: give Flovent HFA

Education: the child must enlighten on the triggers and how to avoid them. He must always take his drug whenever he notices a symptom. Moreover, he must avoid spaces where people smoke for safety.

Follow-up: report to the clinic after 4 weeks of therapy for further assessment.

References

Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in pediatrics, 7, 246.

Forbes, H., & Watt, E. (2020). Jarvis’s Health Assessment and Physical Examination-E-Book: Australian and New Zealand. Elsevier Health Sciences. Soap Notes For Pediatric Cases Assignment Paper

SOAP note: Annual physical examination

Patient information

Patient initial: R.T.     Age: 15.       Sex: female      Race: Caucasian

CC: Annual physical examination

HPI: R.T., a 15-year-old Caucasian female, came at the clinic by herself for her regular health check. She reported no problems with her health and noted that her last appointment, on 5/6/2021, had resulted in normal lab and physical findings. Furthermore, she reported conducting BSE practically every day and has not noted any strange masses. Denies nausea, vomiting, and diarrhea.

Medication: none reported

Allergy: NKFDA

PMHx: no past medical/surgical history reported.

Immunization: up-to-date. Last received Tdap 5/7/2021

Family history: no significant family history reported

Social history: The patient is her parents’ lone child. She is heterosexual, has a boyfriend, and has stated not using any type of contraceptives. She is currently in tenth grade. Lives with her mother in a safe neighborhood. Denies having ever smoked or used alcohol. Rarely exercise and wears a seat belt while driving. Eats a lot of fruits and veggies.

Reproductive history: Began menses at 12 years. LMP 5/7/2022. Follows 28-day cycle. Nulliparous

ROS:

General: denies fever, chills, and changes in weight.

HEENT: no issue with vision or hearing is reported.

CV: no chest pain or sudden changes in heart beat reported.

GI: denies nausea, vomiting and diarrhea.

GU: denies dysuria and polyuria

Msk: denies muscle pain and any other orthopedic injuries.

Skin and breast: deny skin rashes or bruising, breast lump or breast pain.

Neurological: denies cold or heat intolerances

O

PE:

Vts: T 37.1, HR 80, RR 20, BP 128/66, SpO2 100% Wt. 126 lb. Ht. 5’2 BMI 20.4

General: A&Ox3. Well hydrated and appears stated age.

Skin: no rashes or bruises noted.

HEENT: normocephalic, EOMI. PERRLA. Nares patent bilaterally. No buccal nodules noted. No JVD

CV: RRR, no murmur or galops

Msk: symmetrical with ROM intact.

Resp: no cyanosis. Clear lung sound.

Neurological: balanced gait. Speech clear.

Psychiatric: oriented to place and time. Good Insight and judgement (Jarvis et al.,2018)Soap Notes For Pediatric Cases Assignment Paper.

A.

Encountered for physical examination with no abnormal findings.

Due to her sexual history, she needs to be screened for STIs (Shafii et al.,2020).

Lab test and result

CBC: result pending

STD panel test: result pending

UA: result pending

P

Medication: no medication is recommended in her case.

Education: must be advised on dangers of having unprotected sex. Be encouraged to take part in exercise at least 3x a week.

Follow-up: schedule next annual physical examination 6/7/2023

References

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Shafii, T., & Levine, D. (2020). Office-based screening for sexually transmitted infections in adolescents. Pediatrics, 145(Supplement_2), S219-S224.

SOAP note: Right Ankle Sprain

Patient information

Patient initial: G.H.     Age: 10.       Sex: male      Race: Caucasian

CC: Right ankle sprain

HPI: G H, a 10-year-old Caucasian boy, presented at the clinic with her grandmother, complaining of a right ankle sprain that had begun three weeks ago. He reported injuring his foot while playing football with his classmates 6 weeks ago, and the discomfort, which he rated 6/10, persisted despite him taking Calpol 60ml on a regular basis. He claims that the discomfort intensifies when he walks even a short distance, which has interfered with his academic activities. Denies experiencing nausea, vomiting, or diarrhea. Soap Notes For Pediatric Cases Assignment Paper

Medication: Calpol 60ml 10ml PO prn

Allergy: NKFDA

PMHx: no chronic illnesses reported.

Immunization: up-to-date

Family history: no significant family history reported

Social history: The patient is the first born in the family of three children. He is currently in fourth grade at a public school nearby. He mentioned playing football with his acquaintances every weekend. No history of alcohol or tobacco used reported. Live in a safe neighborhood with his grandmother. Eat a healthy food and drinks lots of water always

ROS:

General: denies fever, chills, and changes in weight.

CV: no chest pain reported

GI: denies nausea, vomiting and diarrhea.

Msk: reported right ankle pain which worsens with walking.

Neurological: denies cold or heat intolerances

O

PE:

General: Awake and oriented. Well developed and appear his stated age.

Skin: no rashes or bruises noted.

HEENT: normocephalic, EOMI. PERRLA.

CV: RRR, no murmur or galops

Msk: no significant tenderness noted in both knees. Right ankle is swollen and there is decrease mobility in the affected limb.

A.

Right Ankle sprain

Lab test and result

X-ray: result pending

Differential diagnoses:

1. Ankle sprain (Herzog et al.,2019).
2. Ankle fracture
3. Ankle impingement syndrome

Primary diagnoses: Ankle sprain

1. P.

Medication: Give Motrin 200mg 10ml PO TID

Non-pharmacological: use ice therapy for 15 to 20 minute and take enough rest (Miranda et al.,2021)Soap Notes For Pediatric Cases Assignment Paper.

Follow-up: return to the clinic if the symptoms persist or worsens for further intervention.

Referral: to the orthopedic specialist in case of complication.

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References

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.

Miranda, J. P., Silva, W. T., Silva, H. J., Mascarenhas, R. O., & Oliveira, V. C. (2021). Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function and recurrence in acute ankle sprain: a systematic review of randomized controlled trials. Physical Therapy in Sport, 49, 243-249 Soap Notes For Pediatric Cases Assignment Paper