Describe whether the patient presented with any growth and development or psychosocial issues.

 

Case Study: With this patient in mind, address the following in a SOAP Note:( I HAVE INCLUDED A SAMPLE SOAP NOTE FOR REFERNECE ONLY )

 

A 3 y/o African American female   who present with her mother with a complaint of coughing for a week. Mother reports that she has been coughing every night. She has also had a mild fever of 100.5 at home. Her mother has been using a decongestant/antihistamine syrup and albuterol syrup at home from her previous prescription. Initially the cough improved but it worsened over the last 3 days. She is noted to have morning sneezing and nasal congestion and she goes to pre-school where some of her classmates were noted to be sick. She has no know allergies and up to date with immunization. Previous medical condition is asthma that has been controlled by albuterol inhaler and Nebulizer as needed

 

With this patient in mind, address the following in a SOAP Note:

 

•Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

 

•Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

 

•Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

 

•Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

 

•Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

 

Reference

 

Readings

 

•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

 

◦Chapter 31, “Respiratory Disorders” (pp. 708–738)

•Chapter 40, “Genetic Disorders” (pp. 1032–1054)

 

•Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., Swanson, J. T. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 53(7), e25–e76. Retrieved from the Walden Library databases.

•National Heart, Lung, and Blood Institute. (2007). Expert panel report 3 (EPR3): Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

•Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis by  Ralston, S.L., Lieberthal ,A.S., Meissner, H.C., Alverson, B.K., Baley, J.E., Gadomski ,A.M., Johnson, D.W., Light, M.J.,

SOAP ANALYSIS FOR DIGESTION MALFUNCTION 2

SOAP Analysis for Digestion Malfunction

Student’s Name

Institution

Course Instructor

Date

SUBJECTIVE DATA:

Chief Complaint (CC): A 3-year-old African American healthy boy was brought to the linic by his mother for a well care visit and was complaining that his boy has been straining a lot and cries during bowel movement, she noticed for a week now that has been having difficulty moving his bowel, they have already started him on toilet training he goes to day care . States that she has been preparing his food and package for day care and because he likes rice , she has been feeding him a lot of rice and his son seem not to like fuits and vegetable so she has not packed any fruits and vegetable for a week now .He is current with his immunization and does not have any dvelpoment problem, he is witnin his developmental milestone.Mother states that the toddler does not have any prior medical problem.

History of present conditions: The patients’ mother explains of the patient’s condition of defecating only twice a week. The feces are described to be brown in color, hard and round. The parent explains that the condition had started a while back when the patient had started to train using the potty. From the explanation, it can be perceived that the patient experiences difficulty and pain in the process of defecation with significant difficulty in bowel movement. The condition the patient is in may be as a result of lack of intake of fruits and vegetables.

Medications: Hydrocortisone, biological treatments, ointments, creams, sclerotherapy injection, sigmoidoscopy or colonoscopy, laxatives and high fiber food intake (Annigan & Demand Media, 2015).

Allergies: No general known allergies

Past Medical History (PMH):

1. Low fiber intake in the diet with low vitamin C and K hat needs rectification

2. Cases of constipation with insufficient fibers and roughages to help in digestion

3. Difficulty in bowel movements in defecation process.

4. Hypothyroidism with the body producing insufficient thyroid hormone.

5. Development of hemorrhoids in the rectum.

Past Surgical History (PSH):

None in this case

Sexual/Reproductive History:

Not applicable in the case

Significant Family History: The patient has no related history in the family line as it is a dietary malfunction and thus can be rehabilitated with a recommended diet.

Review of Systems:

General: Strenuous defecation process, loss in weight, lack of appetite, hard stool,

HEENT: The patient has a normal body physique, normal development pattern, functioning body organs, normal digestion process, normal blood pressure and body temperature and no documented diseases.

OBJECTIVE DATA:

Physical exam:

Vital indication B/P 115 /73; P 72 and regular; T 97.3 orally; RR 17; non-labored; Wt.: 30 lbs.; Ht: 1’7; BMI 18

General: A&O x3, NAD, appears mildly uncomfortable

Chest/Lungs: CTA AP&L

Heart/Peripheral Vascular: RRR without murmur, rub, or a gallop; pulses+2 bilat pedal and +2 radial

Neuro: CN II – XII wholly integral, DTR’s integral

BD: benign, nabs x 4, no organomegaly; slight suprapubic sensitivity – diffuse – no rebound

Musculoskeletal: symmetric muscle development

Genitalia/Rectal: external genitalia with irritations, no cervical signal tenderness, no adnexal masses.

Normal development and social interactions with members of the family

ASSESSMENT:

Laboratory evaluations and Results:

CBC – WBC 15,000 with left change (Moores & Deborah, 20152).

Differential Diagnosis (DDx):

1. Constipation

2. Hemorrhoids

3. Hypothyroidism

Diagnostics:

Laboratory

Hemorrhoidectomy

Normal sinus rhythm

The primary diagnosis is the laboratory test to test the probability of the second and third differential diagnostics; Haemorrhoids and Hypothyroidism. Apart from it, the case of constipation is most probable for the patient (Norman, 2014).

PLAN:

Diagnostic and treatment: The plan was to diagnose the patient with constipation as a result of dietary intake with the possibilities of hemorrhoids and hypothyroidism. The treatment plan would involve taking of laxatives that would aid in the softening of the patient’s stool. Ointment and cream prescribed obtained from the clinic or over the counter would help relieve the irritation in the genital. Continue high fiber diet and increase fluid intake : Mother is advised to increase the roughage intake in the child’s diet , provided handout on how to avoid constipation in children, dietry pamphlets for children healthy eating provided to the mother , encouraged need to increase fluid intake . Increasing the deprived intake by 20% will solve the condition (Seidel, 2011).

REFLECTION

The “aha” moment is when I found out the toddler is encountering difficulties in the passing stool due to high intake of carbohydrate food and low intake of high fiber diet that I linked to the classroom studies that described the importance of fibers and roughages in the diet. The characteristics of problems with bowel movement have been greatly attached to constipation (Dinesen, 2015).

References Annigan, J., & Demand Media. (2015). Consequences of not eating Fruits and vegetables. SF Gate : Healthy Eating. Dinesen, C. (2015). The effects of eating too few vegetables. Livestrong.com, 1-5. Moores, D., & Deborah , W. (2015). Complete blood count (CBC). Healthline. Norman, J. (2014). Hypothyroidism: Too little thyroid hormone, causes symptoms, diagnosis, and treatment. Endocrine web, 1-3. Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.