Soap note week two peds

NOTE: We do not resell pre-written papers. Upon ordering a paper, we custom-write an original paper exclusively for you. Please proceed and order an original paper to enjoy top grades.


Order a Similar Paper Order a Different Paper

For this Assignment the instruction are attach as well as an example ppt/ template for the soap noted.

please read the entire instructions before do the assignment. THIS ASSIGMENT IS ALREADY TWO DAYS LATE AND I NEED ALL THE POINTS I CAN GET SINCE ITS LATE I WILL HAVE POINT DEDUCTED ALREADY. if you cannot give this assignment on time or you cannot preform the soap note/ppt than please let me asap.

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

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)

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 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 home 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

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

Review of Systems

• CONSTITUTIONAL: No night sweats. No fatigue, malaise, 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 diarrhea 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 right great toe for
past 3 days. No prior history of gout, No arthritis. No surgery in foot or ankle or leg. Difficulty bearing
weight on 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 gets occasionally 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
noted. No calculi or scarring 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 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.

"Is this question part of your assignment? We can help"

ORDER NOW
Writerbay.net

Do you need help with an assignment? We work for the best interests of our clients and maintain professionalism to offer brilliant writing services in most of academic fields—ranging from nursing, philosophy, psychology, biology, finance, accounting, criminal justice, mathematics, computer science, among others.


Order a Similar Paper Order a Different Paper