Pediatric – week 2 clinical case report soap narrate powerpoint

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

 Full instructions on WORD DOCUMENT. Please read the full document and check the PP example for reference.  

Infectious Mononucleosis

Jane Doe

NSG6435 Family Health – Pediatric

7/19/2022

1

Infectious Mononucleosis

Chief Complaint

A 17-year-old student present with the complaint of fever, sore throat, and malaise that has been their for several days. She present with a new rash that is developed today (Baros et al., 2019).

A 17-year-old student present with the complaint of fever, sore throat, and malaise that has been their for several days. She present with a new rash that is developed today.

3

HPI

The patient is having worsened sore throat, fever, malaise, and new rashes (location) that has been therefore for several days with todays’ development of the new rash (Onset) and four day ago, he had a temperature of 103 F that has persisted (duration). The sore throat has worsened and having difficulty swallowing solid foods and drinking well (character). The sore throat becomes worse as she tries to swallow or drinks (aggravating). She has been taking oral contraceptives on the daily basis and amoxicillin yesterday (alleviating) and helps with the severe sore throat. The sore throat becomes worse with swallowing and drinking (radiation). He rates the pain as a 6/10 on the pain scale(severity). She reports mild supraorbital edema, bilateral enlarged tonsils coated with gray exudate (temporal).

The patient is having worsened sore throat, fever, malaise, and new rashes (location) that has been therefore for several days with todays’ development of the new rash (Onset) and four day ago, he had a temperature of 103 F that has persisted (duration). The sore throat has worsened and having difficulty swallowing solid foods and drinking well (character). The sore throat becomes worse as she tries to swallow or drinks (aggravating). She has been taking oral contraceptives on the daily basis and amoxicillin yesterday (alleviating) and helps with the severe sore throat. The sore throat becomes worse with swallowing and drinking (radiation). He rates the pain as a 6/10 on the pain scale(severity). She reports mild supraorbital edema, bilateral enlarged tonsils coated with gray exudate (temporal).

4

Medical History

Worsened sore throat

Difficulty swallowing solid foods

Based on the case scenario presented, the patient had worsened sore throat and difficulty in swallowing solid foods.

5

Medication History

Daily oral contraceptive that is not mentioned

Amoxicillin

There were some drugs that were used by the patient to help in the reduction of symptoms such as sore throat. Therefore, she took oral contraceptives daily. She also took two doses of amoxicillin yesterday before reporting to the facility.

6

Family Medical History Summary

Father- no history provided

Mother- no history provided

Sister- no history provided

Paternal Grandfather- no history provided

Paternal Grandmother – no history provided

Maternal Grandmother- no history provided

Paternal Grandfather- no history provided

Based on the history of the patient in the case study, there is no any evidence that can be associated with the family history.

7

Social History

Marital status-Unknown

Relationship status-unknown

Substance use-unknown

Alcohol use-unknown

The patient is a 17-year-old but the case study does not provide history about the patient relationship status. There no clear information about the substance or alcohol use about this patient. The case study also lacks information concerning the likes and dislikes of the patient and where she spend most of her time when she is free especially during weekends.

8

Patient Profile

The patient is a 17-year-old

Has the ability to perform the activity of the daily living

She is able to perform the activities without any form of help

Presented herself to the facility for the medical services.

Reports about the medication she used in the past prior to the presentation to the clinic (Baros et al., 2019).

The patient is a 17-year-old and has the ability to perform the activity of the daily living without any form of help. She presented herself to the facility for the medication services. She is able to report about the medication she used in the past prior to the presentation to the clinic.

9

Review of Systems

Constitutional: admits malaise and fever. Denies night sweats, fatigue, and lethargy

HEENT: denies vision changes, pain of the eye, eye discharges. Denies running nose, epistaxis, sinus pain, ear pain, odynophagia, and congestion. Admits sore throat

Breasts: denies breast pain, lumps, and discharges.

Cardiovascular: denies chest pain and palpitations

Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation, and hematemesis

Genitourinary: denies frequent, urge, dysuria, hematuria, obstructive symptoms, discharges, pain, or bleeding

Based on the information provided by the patient, she admits to be having malaise and fever. She denies experiencing night sweats, fatigue, and lethargy. She also denies changes in the vision, eye pain, eye discharges, running nose, epistaxis, sinus pain, ear pain, odynophagia, and congestion. She admits having sore throat. She denies breast pain, lumps, and discharges.

She report no chest pain and palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, denies frequent, urge, dysuria, hematuria, obstructive symptoms, discharges, pain, or bleeding

10

Cont’d

Musculoskeletal: denies joint pain, swelling.

Neurological: denies seizure, syncope, confusion, neck pain, weaknesses, and headache.

Psychiatric: denies confusion

Skin: admits the presence of rashes

Endocrine: denies weight loss, polyuria, polydipsia, and polyphagia

Hematologic: denies excessive bleeding, petechiae, purpura, and anemia

Allergic and Immunologic: denies the presence of swelling or pruritus

She denies joint pain, swelling, seizure, syncope, confusion, neck pain, weaknesses, and headache. She reports no confusion, admits the presence of rashes, weight loss, polyuria, polydipsia, and polyphagia. She denies excessive bleeding, petechiae, purpura, anemia, swelling or pruritus,

11

Physical Examination

Vital signs: Temp: 102.2 o F, B/P 130/80, HR 105, RR 20, Ht 64’’, Weight 120 pounds

Mild supraorbital edema

Bilateral enlarged tonsils coated with gray exudate

Few petechiae on palate and uvula

Bilateral posterior cervical lymphadenopathy

Spleen palpable 3 cm below the coastal margin

The physical examination reveals that the patient has a temperature of 102.2 o F, B/P 130/80, HR 105, RR 20, Ht 64’’, Weight 120 pounds. The patient has mild supraorbital edema bilateral enlarged tonsils coated with gray exudate. The patient also has few petechiae on palate and uvula. There is bilateral posterior cervical lymphadenopathy and a spleen palpable 3 cm below the coastal margin

12

Laboratory or Diagnostic Examination Outcomes

White blood cell (WBC): 17,000 cells/mm3

Lymphocytes: 50 percent

Atypical lymphocytes: 15 percent

Platelet count: 100,000/mm3 (Baros et al., 2019)

White blood cell (WBC) count of 17,000 cells/mm3 with 50% lymphocytes, 15% atypical lymphocytes, and a platelet count of 100,000/mm3.

13

Risk Factors for Infectious Mononucleosis

Sharing drinks, toothbrushes, and anything that touches saliva or mouth

Sexual contact

Blood transfusion

Organ transplant

Compromised immune system that exposes individuals to EBV or viral infection that reactivates and cause second bout of the monomnucleosis (Rostgaard et al., 2019)

There are various factors that are linked to the increase in the risk of infectious mononucleosis. Some of the risks include sharing of the drinks, toothbrushes, and anything that touches on the mouth and saliva. There is also sexual contact, blood transfusion, compromised immune system that exposes individuals to develop EBV and the virus reactivating and causing second bout of mono.

14

Cont’d

Diagnosis and differential diagnosis

Primary diagnosis:

Infectious mononucleosis (B27.90): the condition is characterized with extreme tiredness, high fever, headache, body aches and muscle weakness, red or sore throat, rashes, and swollen glands.

Differential diagnosis:

Cytomegalovirus (B25.9): the condition present in the form of high temperature, aching muscles, tiredness, skin rashes, sore throat, and the feeling of sickness.

The condition is ruled out since the patient never reported longer duration of temperature (Ishii et al., 2019).

Infectious mononucleosis (B27.90): the key symptoms include extreme tiredness, high fever, headache, body aches and muscle weakness, red or sore throat, rashes, and swollen glands.

Differential diagnosis: Cytomegalovirus (B25.9): the common features of this condition include high temperature, aching muscles, tiredness, skin rashes, sore throat, and the feeling of sickness.

The condition is ruled out since the patient never reported longer duration of temperature

16

Cont’d

Human immunodeficiency virus (HIV) (B20): characterized with fever, chills, rashes, night sweats, muscle aches, sore throat, fatigue, and swollen lymph nodes. Ruled out since the patient never had chills

Human herpesvirus type 6 (B10.81): the disease is characterized with sudden high fever that lasts for three days, running nose, coughing, mild diarrhea, swollen lymph node within the neck, irritability, and reduction in appetite.

The condition is ruled out since the patient never presented running nose, diarrhea, coughing, and reduced in appetite (Ishii et al., 2019)

It is also likely that the patient might be having HIV and the common symptoms include fever, chills, rashes, night sweats, muscle aches, sore throat, fatigue, and swollen lymph nodes. However, it is ruled out since the patient never had chills. Another potential condition is human herpesvirus type that has symptoms of sudden high fever that lasts for three days, running nose, coughing, mild diarrhea, swollen lymph node within the neck, irritability, and reduction in appetite. Nevertheless, the condition is ruled out since the patient never presented running nose, diarrhea, coughing, and reduced in appetite.

17

Cont’d

Treatment

Management using pain relievers and fever reducers

These medications include ibuprofen and acetaminophen is used.

Home remedy using salt water gargles

The salt water gargles are used for sore throat.

Patient to take rest

Avoid sports until symptoms disappear.

This disease is a virus, therefore it cannot be treated using antibiotics. Therefore the management of the symptoms is done using pain relievers and fever reducers, in this case medications like ibuprofen and acetaminophen is used. Home remedy can include salt water gargles for the sore throat. The patient can be advised to rest and avoid sports until the symptoms disappears.

19

Cont’d

Teaching and Health Promotion

Health promotion practices is important in the management of this condition.

Patient is advised to wash hands after bathrooms and after eating.

Patient informed to cough or sneeze into sleeve or tissue

She is advised to wash hands after sneezing and coughing.

Patient informed to avoid individuals with this condition or symptoms of this disease

She is advised to stay home from work or school in case she develops the symptoms again.

She is advised not to share objects that comes into contact with the mouth (Poorebrahim et al., 2017).

The management of this condition requires health promotion practices. Therefore, the patient is advised to wash hands after using bathrooms and after eating. The patient is advised to cough or sneeze into sleeve or tissue and wash hands afterward. The patient is advised to avoid individuals with this condition or symptoms associated with mononucleosis until they recover. The patient is advised to stay home from work or school in case they have symptoms. The patient is advised not to share objects that comes into contact with the mouth.

21

Cont’d

The patient is also advised to care for the rashes.

Advised to avoid harsh soaps and detergents.

Advised to avoid perfumed soaps or lotions.

Patient informed to use antihistamine or steroid cream to help with rashes

Avoid strenuous activities for 3 weeks

The patient is also advised to care for the rashes. She is advised to avoid harsh soaps and detergents. She is also advised to avoid perfumed soaps or lotions. She is advised to use antihistamine or steroid cream to help the situation she is advised to refrain from strenuous activities for the first 3 weeks

22

Follow-up

The patient followed for the medication adherence.

Patient return to the facility after 14 days

This helps in monitoring the potential changes in the symptoms.

The scheduled routine visits help in monitoring the course of illness

It also helps in detection of potential complications.

Follow-up done to give medical clearance for the resumption of strenuous activities

A follow-up is plan for sonographic diagnosis.

The patient is followed for the medication adherence. She is advised to return to the facility after 14 days to help in monitoring the potential changes in the symptoms. The schedule routine visits with the healthcare provider is doe to help in monitoring the course of illness and detection of potential complications. The follow-up is done to give medical clearance for the resumption of strenuous activities or contract sports. A follow-up is plan for sonographic diagnosis.

23

References

Barros, M. H. M., Vera-Lozada, G., Segges, P., Hassan, R., & Niedobitek, G. (2019). Revisiting the tissue microenvironment of infectious mononucleosis: identification of EBV infection in T cells and deep characterization of immune profiles. Frontiers in immunology, 10, 146.

Ishii, T., Sasaki, Y., Maeda, T., Komatsu, F., Suzuki, T., & Urita, Y. (2019). Clinical differentiation of infectious mononucleosis that is caused by Epstein-Barr virus or cytomegalovirus: A single-center case-control study in Japan. Journal of Infection and Chemotherapy, 25(6), 431-436. Doi: 10.1016/j.jiac.2019.01.012

Poorebrahim, M., Salarian, A., Najafi, S., Abazari, M. F., Aleagha, M. N., Dadras, M. N., … & Poortahmasebi, V. (2017). Regulatory network analysis of Epstein-Barr virus identifies functional modules and hub genes involved in infectious mononucleosis. Archives of virology, 162(5), 1299-1309.

Rostgaard, K., Balfour Jr, H. H., Jarrett, R., Erikstrup, C., Pedersen, O., Ullum, H., … & Hjalgrim, H. (2019). Primary Epstein-Barr virus infection with and without infectious mononucleosis. PloS one, 14(12), e0226436.

For this assignment, you are to complete a clinical case – narrated 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

CLINICAL CASE SCENARIO

A 5-year-old male patient presents to your clinic for ear pain. His mother reports he was in good spirits and energetic until about 5 days ago when he developed an upper respiratory infection (URI) consisting of clear nasal discharge and cough. The mother reports that he has been lethargic and stopped drinking fluids about 48 hours before he developed a temperature of 102.1°F and started complaining that his right ear hurt. The mother denies nausea, vomiting, diarrhea, headache, or change in urine output. The mother reports that the patient’s sleep was interrupted due to his complaints of right ear pain.  She noticed that he tugged at his right ear frequently while remaining minimally interested in playing with his toys earlier in the day. Today, his vitals are as follows: weight 40.5 lbs, height 43.0 inches, BP 100/70, HR 100, RR 26, and Temperature is 102F.
Diagnosis: Acute Otitis Media

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

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