PEDS – Week 8 Soap Note with Example

PEDS – Week 8 Clinical Case Report SOAP PowerPoint- PEDS – Week 8 Soap Note with Example

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For this assignment, you are to complete a clinical case – PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.  

You are to approach this clinical scenario as if it is a real patient in the clinical setting.

Instructions:

Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.

Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.

Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.

 

Example of Steps 1 – 3:

You decided on Angina after reading the clinical case scenario (Step 1)

Review of Symptoms (list of classic symptoms):

CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone

GI: indigestion, heartburn, nausea, cramping

Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth

Resp: shortness of breath

Musculo: weakness

 

Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.

 

Example of Step 4:

You determined the patient has Angina in Step 1

Physical Examination (list of classic exam findings):

CV: RRR, murmur grade 1/4

Resp: diminished breath sounds left lower lobe

 

Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.

 

Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following:

a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)

b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)

c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmacological treatments

f) Patient/Family education including preventive care

g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)

h) Follow-up appointment with a detailed plan of f/u

 

As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:

 

FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:

 

DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.

 

SUBJECTIVE (S): Describes what the patient reports about their condition.

For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.

 

Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian

Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash

HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form

PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place

MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies.

Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash

FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc…

SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.

 

Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)

 

HRB (Health-related behaviors):

ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).

 

OBJECTIVE: Physical findings you observe or find on the exam.

1. Age, gender, general appearance

2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart

3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)

4. Lab Section – what results do you have?

5. Studies/Radiology/Pap Results Section – what results do you have?

 

RISK FACTORS: List risk factors for the acute and chronic conditions

 

ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.

 

You are to also list any chronic conditions with the ICD-10 codes.

 

NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan

 

TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.

 

Example:

1. HTN

a) Vaccines administered this visit & vaccine administration forms given,

b) Medication-include dosage amounts and mg/kg for drug and number of days,

c) Laboratory tests ordered

d) Diagnostic tests ordered

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

 

2. HLD

a) Vaccines administered this visit & vaccine administration forms given,

b) Medication-include dosage amounts and mg/kg for drug and number of days,

c) Laboratory tests ordered

d) Diagnostic tests ordered

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

Also discussed:

g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)

Return to the clinic:

h) Follow-up appointment with a detailed plan for f/u and any referrals

 

CLINICAL CASE SCENARIO

A mother brings her 18-month-old son to your clinic because of a persistent facial rash. The child is restless at night and scratches in her sleep. He is otherwise healthy. Today, his vitals are as follows: weight 23.4 lbs, height 31.8 inches, BP 120/76, HR 100, RR 26, and Temperature is 98.6 F. His physical examination reveals a well-nourished, healthy-appearing child with dry, red, scaly areas on the cheeks, chin, and around the mouth as well as on the extensor surfaces of his extremities. The areas on the cheeks have a plaque-like, weepy appearance. The diaper area is spared. The remainder of the child’s examination is normal.

 

Diagnosis – Atopic Dermatitis

 

Week 8 Soap Note Example

Gout Jane Doe

NSG 6435

Faculty

 

Chief Complaint

M.C. is a 55-year-old Caucasian male presenting with complaints of pain, with redness and

swelling in his right great toe.

 

HPI

Historian: (include this information for patients <16 y/o and older patients PRN)

The patient is an obese male who reports pain, redness and swelling in right great toe(location), which started 3 days ago(Onset) and has progressively gotten worse(duration). He describes the pain as a burning constant(character) pain irritated with any touch or friction(aggravating). He tried over-the-counter ibuprofen(alleviating) and states it did mildly help the with the pain. The pain does radiate to the entire foot(radiation), and he cannot bear weight. He rates the pain as a 10/10 on the pain scale(severity). He mentions that he does have daily ethanol ingestion and was recently started on chlorthalidone for hypertension (HTN), which he feels contributed to the flare(temporal).

 

Medical History

• Kidney stones in 2012

• HTN

• Obesity

• No Surgeries

 

Medication Lists

• Ibuprofen – 800mg- tid

• Chlorthalidone 25mg- daily

• No Known Allergies

 

Family Medical History Summary

Father- Died at 72yrs old- hypertension, heart disease, and renal failure.

Mother- Died at age 65 of breast Cancer.

Sister- Age 55- Alive and well – HTN

Paternal Grandfather- Unknown

Paternal Grandmother – Died at age 82yr- Heart Disease

Maternal Grandmother- Dies at 87yr- Stroke- HTN and Diabetes

Paternal Grandfather- Died at 62 yrs in a car accident

 

Social History

C.M – Is divorced and lives alone. He was married for 20 years and has 1 male child, age 28yr. He works full-time as a manager of a local Tires Plus. He rents an apartment in the local town in which he works. He is in a monagomous relationship with a female partner for the past 2 years.

C.M. does not smoke. He drinks 2-3 alcoholic drinks per day. He reports sleeping 5-6 hours daily, and exercises twice weekly. He drinks 2-3 caffeinated beverages per day and eats at a fast food restaurant 4-5 days a week. He does eat beef daily.

He does report a history of methamphetamine abuse from ages 20-22. He was admitted to a drug rehabilitation program and has been drug-free for 30 years.

 

Patient Profile

Activities of Daily Living (age appropriate): Independent

Safety Practices: 2 firearms in the home are secured in a gun closet

Changes in daycare/school/after-school care: (address if appropriate)

Developmental History: (provide a history of development over the child’s lifespan. If

the child is 1y/o or younger, provide birth history also)

 

Review of Systems

• CONSTITUTIONAL: No night sweats. No fatigue, malaise, or lethargy. No fever or chills.

• HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis, No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.

• BREASTS: No breast pain, soreness, lumps, or discharge.

• RESPIRATORY: No cough. No wheeze. No hemoptysis. No shortness of breath.

• CARDIOVASCULAR: No chest pains. No palpitations.

• GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No diarrhoea or constipation. No hematemesis. No hematochezia. No melena. BM- daily

• GENITOURINARY: No urgency. No frequency. No dysuria. No hematuria. No obstructive symptoms. No discharge. No pain. No significant abnormal bleeding.

 

Review of Systems

MUSCULOSKELETAL: musculoskeletal pain in right foot and toe and joint swelling in the right great toe for the past 3 days. No prior history of gout, No arthritis. No surgery in the foot or ankle, or leg. Difficulty bearing weight on the right foot. “Warmth, pain, swelling, and extreme tenderness in a joint, usually a big toe joint (Podagra) Red or purplish skin around the affected joint (in-text citation from textbook).”

NEUROLOGICAL: No confusion or weakness. No headache or neck pain. No syncope or seizure.

PSYCHIATRIC: He occasionally gets confused.

SKIN: No rashes. No lesions. No wounds.

ENDOCRINE: No unexplained weight loss. No polydipsia. No polyuria. No polyphagia.

HEMATOLOGIC: No anemia. No purpura. No petechiae. No prolonged or excessive bleeding.

ALLERGIC AND IMMUNOLOGIC: No pruritus. No swelling.

 

Physical Examination

• Vital signs – Temp 99.1, Pulse 100,

respiration -24, BP-151/95.

• Swelling and erythema in right great

toe. “Nodules

• Pain and tenderness to right toe

and right foot with palpation

• 2+ edema to right foot

 

Physical Examination

• “Warmth, redness, swelling, and decreased range of motion of the affected joint or joints. The initial episode is usually monoarticular in men. The first metatarsophalangeal (MTP) joint is the initial one involved in approximately half the patients. Acute synovitis of the first MTP joint of the big toe is referred to as podagra. Other joints involved (in decreasing order of frequency) are insteps, heels, knees, wrists, fingers, and elbows. In his classic description of the onset of an acute flare (in-text citation).”

 

Labs/Diagnostic Exam Results

CBC – white blood count elevated at 12,000.

His pertinent laboratory values reveal a mild leukocytosis and increased erythrocyte sedimentation rate.

Serum uric acid (SUA) level is 11.6 mg/dL. His SCr and BUN are elevated.

A synovial fluid aspirate of the affected toe joint contains white blood cells and monosodium urate crystals, confirming the diagnosis of gout.

• Comprehensive Chemistry – LFT’S- elevated- AST- 48, ALT- 38 GFR-<90,

• Renal Ultrasound –mild hydronephrosis of the left kidney noted. No renal abscess was noted. No calculi or scarring was noted.

 

Risk Factors for Gout

• Male

• Diet – limit foods with high –purine content

• Alcohol

• Obesity

• Renal Failure- High Blood Pressure

• Medications- Chlorthalidone

 

Diagnosis and Differential Diagnosis

• Acute Diagnosis – Gout M10.9

Differential Diagnosis

1. Pseudogout M11.20

2. Cellulitis L03.90

3. Rheumatoid Arthritis M06.9

• Chronic Diagnosis

1. Hypertension 401.9

2. Obesity E66.9

 

Diagnosis and Differential Diagnosis

Acute Diagnosis – Gout M10.90

Include the Definition of Gout

Include Pertinent Positives &

Negatives

Diff Dx – Pseudogout M11.20

Include the Definition of Pseudogout

Include Pertinent Positives & Negatives

 

Diagnosis and Differential Diagnosis

Diff Dx – Cellutitis L03.90

Include the Definition of Gout

Include Pertinent Positives &

Negatives

Diff Dx – Rheumatoid Arthritis M06.90

Include the Definition of Pseudogout

Include Pertinent Positives & Negatives

 

National Clinical Guidelines

Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and Prevention of Gout. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1215/p831.html

Armstrong, C. (2014, October 01). JNC8 Guidelines for the Management of Hypertension in Adults. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1001/p503.html

 

Treatment of Gout

Gout

• a) Medication-include dosage amounts and mg/kg for drug and number of days,

b) Laboratory tests ordered

c) Diagnostic tests ordered

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmaceutical treatments

f) Patient/Family education including preventive care

(Hainer, Matheson, & Wilkes, 2014)

 

F)Teaching/Health Promotion

• Educate patient and family that frequent post-treatment surveillance for

recurrent infection until 4–6 weeks postpartum is recommended. Monthly

urinalysis for culture and sensitivity for 3 months, use of Macrobid as

suppressive therapy, and initiating prevention strategies will reduce the risk

of acute pyelonephritis recurrence.

• Educate patients on strategies for preventing acute gout flares including

adequate fluid intake, avoidance of high–purine foods(e.g., beef, seafood,

coffee, tea, colas, alcohol) medications as directed to reduce uric acid concentrations.

 

Treatment of HTN

HTN

• a) Medication-include dosage amounts and mg/kg for drug and number of days,

b) Laboratory tests ordered

c) Diagnostic tests ordered

d) Vaccines administered this visit & vaccine administration forms given,

e) Non-pharmaceutical treatments

f) Patient/Family education, including preventive care

(Armstrong, 2014)

 

Follow-up

g) Anticipatory guidance for visit (be sure to include exactly what you discussed during visit; review

Bright Futures website for this section), and

h) Follow-up appointment with detailed plan of f/u

 

References continued

Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and

Prevention of Gout. Retrieved September 03, 2020, from

https://www.aafp.org/afp/2014/1215/p831.html

McCance, K. & Huether, S. (2014). Pathophysiology: the biologic for disease in adults and children, (7th

ed), St. Louis: MO; Elsevier/Mosby.

MeeOnn, C. & Amir-Ansari, B. (2012). Disease profile: pyelonephritis. Journal of Renal Nursing,

4(3), 128-130.

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