NSG6435 Week 9 SOAP On Infectious Disease

NSG6435 Week 9 SOAP on Infectious disease

Name:	Date:
Sex:	Age/DOB/Place of Birth:
SUBJECTIVE
Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)
HPI: (must include all components)
Medications: (List with reason for med )
PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations:
Family History (*Please identify all immediate family)*
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General		Cardiovascular
Skin		Respiratory


Eyes		Gastrointestinal
Ears		Genitourinary/Gynecological
Nose/Mouth/Throat		Musculoskeletal
Breast		Neurological
Heme/Lymph/Endo		Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) *Attach growth chart*
Weight	Temp		BP
Height	Pulse		Resp
General Appearance and parent‐child interaction
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary

Musculoskeletal

Neurological

Psychiatric

In-house Lab Tests – document tests (results or pending)

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

Diagnosis

Ø Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

Ø Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

Ø Primary diagnosis

ü Is #1 on list of differentials

ü Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

PLAN including education

Ø Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

Ø Include EB rationale for all aspects of your treatment plan:

ü Vaccines administered this visit

ü Vaccine administration forms given

ü Medication-amounts and mg/kg for medications

ü Laboratory tests ordered

ü Diagnostic tests ordered

ü Patient education including preventive care and anticipatory guidance

ü Non-medication treatments

ü Follow-up appointment with detailed plan of f/u

*ALL references must be Evidence Based (EB)

SAMPLE SOLUTION

Sample SOAP on Infectious disease

Name: B. N		Date:
Sex: F		Age/DOB/Place of Birth: 8 years old
SUBJECTIVE
Historian: Mother Present Concerns/CC: “She has not been feeling well for the past 3 days.”
Child Profile: The patient is an 8-year-old female who was brought to the hospital by her mother, appearing to be in pain. She, however, looks healthy and well nourished. Her communication skills and development are age appropriate. She is currently in the 3^rd grade and performs well as stated by her mother. Before she started feeling unwell, the mother claims that she was very playful. However, after she got ill, she has not been able to get out of bed.
HPI: B.N is an 8 years old female patient who was brought by her mother complaining that she was is in pain. Her mother stated that she has been ill for the past 3 days. She complained of fever, productive cough and sore throat. She also claimed that B.N has been feeling very tired lately and unable to go to school. The patient, however, has no previous history of any medical condition that required medical attention or chronic care. Her mother suspects that she might be having an infection.
Medications: Ibuprofen for the past two days to manage fever
PMH: The patient was a planned pregnancy with proper prenatal care. Her mother was healthy during the pregnancy with proper diet and required supplements such as folic acid. She has no history of smoking, drinking alcohol or using any illicit drugs. During pregnancy, she had a 27-pound weight gain and delivered vaginally with no complications. Allergies: none that is known of Medication Intolerances: none Chronic Illnesses/Major: none Traumas: None Hospitalizations/Surgeries: no surgical history or hospitalization. Immunizations: up to date.
Family History: B.N is the third born in a family of four. The father is 38 years old, and the mother is 35 years old. Her older brother is 10 years old. They are all healthy. However, her grandmother has high blood pressure and her grandfather was diagnosed with CAD and HTN.
Social History: B.N lives together with her mother father and older brother in a 3-bedroom apartment in a middle-class neighborhood. She is currently in the 3^rd grade with good performance. She likes swimming and dancing. Both her parents deny alcohol, tobacco or substance use. Her mother claims that her neighborhood is safe, and she has never had a traumatic experience.
ROS
General: The mother claims that the patient is ill and fatigued every time. She, however, eats a balanced diet and takes an adequate amount of water. She denies weight changes or sleep issues.		Cardiovascular: Denies chest tightness, chest pain, palpitations. No signs of edema or orthopnea.
Skin: Denies itchy skin, rashes or lesions.		Respiratory: The mother confirms productive cough with yellow mucoid sputum for the past 4 days. Complains of wheezing and shortness of breath.
Head: Her head appears to be normocephalic. Denies any history of physical injuries or head trauma.		Breast: No skin color changes, lumps, or nipple discharge or tenderness.
Eyes: Denies noticing diplopia, excessive tearing, blurry vision and changes in visual acuity.		Gastrointestinal: Denies nausea and vomiting, abdominal pain, diarrhea, constipation, bloating or any color changes of the stool.
Ears: Denies ear pain, drainage or hearing loss.		Genitourinary/Gynecological: The mother denies any changes in urine frequency, urine color or urgency.
Nose/Mouth/Throat: Denies nasal discharge, bleeding gums, nasal congestion or drooling. She, however, complains of sore throat and fever for the past 2 days.		Musculoskeletal: Denies back pain, joint stiffness, pain, swelling or fractures.
Developmental Problems: No development problems reported.		Neurological: Denies transient paralysis, syncope, general weakness, seizure, or sleeping difficulties.
Heme/Lymph/Endo: Denies any history of blood transfusion, night sweats, swollen glands, cold or heat intolerance, increased thirst or increased hunger.		Psychiatric: Denies any history of mental disorders. No signs of depression or anxiety.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) *Attach growth chart*
Weight: 54 lbs. BMI: 16	Temp: 101^oF		BP: 110/72 mmHg
Height: 124 cm	Pulse: 84 b/m		Resp: 25
General Appearance and parent‐child interaction: The patient is currently ill appearing. She feels tired most of the time and unable to go to school. She is however clean and well groomed. She denies any changes in the patient’s weight.
Skin: Light skin, warm, dry, clean and intact. No signs of rash or lesions noted.
HEENT: Head: normocephalic and atraumatic with evenly distributed hair with no lesions. No tender, no rashes, scales, masses or lumps noted. Eyes: with n rash, PEERLA. No conjunctiva or sclera infection. No visual defects. Ears: no tenderness or redness. Intact auditory meatus. No pain upon palpitation. Passed the whisper test bilaterally. Nose: pink nasal mucosa, inflamed with normal turbinate. No sinus pressure or nasal septal deviation. Neck and Throat: Full ROM, no occipital nodes or cervical lymphadenopathy. No nodules or thyromegaly. Pink and moist oral mucosa. Nonerythematous pharynx with no exudates. The patient complains of sore throat.
Cardiovascular: S₁S₂are audible. Regular heart rate and rhythm with no murmurs, rubs, gallop or clicks. Palpable Pulses 4+. No signs of edema. Sample SOAP note on Infectious disease
Respiratory: No signs of shortness of breath or wheezing or rales. The regular rate of respiration. Symmetrical chest walls. No signs of intercostal retractions or dyspnea. Presence of productive cough with yellow mucoid sputum.
Gastrointestinal: Soft abdomen, non-tender with no masses. The abdomen has no rigidity or rebound or guarding. Bowel sounds active in all the 4 quadrants.
Breast: No tenderness, masses, secretions or discoloration.
Genitourinary: No rashes or any signs of infections are the external genitalia. No distention of the bladder. No CVA tenderness.
Musculoskeletal: No bruising, swelling, or deformity noted. Full ROM noted in all the 4 extremities.
Neurological: Stable balance with gait. Intact mental status. Symmetric reflexes with spontaneous movement of all the extremities. Intact sensation. Clear speech tones. Stable posture. Appropriate age development.
Psychiatric: No signs of anxiety or depression.
In-house Lab Tests – document tests (results or pending): · Complete blood count with differentials to determine whether the symptoms are as a result of an infection (McInerny, & American Academy of Pediatrics, 2017). · Influenza testing including nasopharyngeal- negative for influenza type B, for assessment of the presence of influenza virus. · Rapid antigen swab test for assessment of strep throat. · Chest x-ray to check for the main cause of the productive cough and rales (McInerny, & American Academy of Pediatrics, 2017). · Sputum culture to check for respiratory tract infections.
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment) Ages and Stages Questionnaires third edition for an 8-year-old. Results: Pass in every domain. The patient meets all the age-appropriate development milestones as per the ASQ-3 evaluation tool (Hagan, Shaw, & Duncan, 2017). Rationale: The patient has no problem with communication, fine motor, gross motor, problem-solving, social and cognitive skills as per the ASQ-3. On the pain scale, her ratings were 2 out of 10, indicating very mild pain. Summary of the findings: Home: Lives together with mother, father, and sister in a 3 bedroomed house. Education: The patient is in the third grade with good performance. The mother is a graduate in Bachelor of Commerce. Eating: Consumes a balanced diet, with lots of fruits and vegetable and an adequate amount of water. She has a good appetite. Activities: Playful and energetic. Enjoys swimming. Drugs: Both the mother and father deny smoking, drinking alcohol or using any illicit drug. Safety: Denies any guns or dangerous weapons at home. She is monitored when swimming.
Diagnosis
1. J10.1 – Type B Influenza: is commonly known as flu. It is a viral respiratory infection characterized by fever, chills, sore throat, rhinitis and nasal congestion as displayed by the patient’s symptoms. Other sign and symptoms for flu are running nose and muscle ache (Longe, 2018). 2. J02.0-Streptococcal pharyngitis: This is a bacterial throat infection characterized by sore throat, painful swallowing, red and swollen tonsils, swollen lymph nodes on the neck, fever, headache, nausea, and vomiting (Nishiyama et al., 2018). The patient displayed symptoms of sore throat and fever. It can be ruled out using the rapid antigen swab test. 3. B97.4 -Respiratory Syncytial Virus Infection: This is an infection of the lungs and respiratory tract. It is characterized by a running nose, dry cough, sore throat, low-grade fever, and mild headache. This differential diagnosis can be ruled out by negative RSV testing (Drysdale, Green, & Sande, 2016). Primary Diagnosis: Influenza Type B J10.1 is the most preferred diagnosis, given the patient’s subjective and objective data. The patient also displays symptoms of chills, fever, sore throat, congestion, and rhinitis. A positive lab test for the Influenza virus will confirm the diagnosis. PLAN including education · Care Plan: Pharmacological management: Administer Oseltamivir Phosphate 75mg capsules orally twice daily for the management of the flu for a maximum of 10 days. Continue administering Tylenol 160mg one tablet four times a day orally for the management of pain and fever (Longe, 2018). Lastly, administer Sudafed syrup, 10 ml twice daily by mouth after every 4 hours for nasal decongestion and sinus pressure. · Non-Pharmacological management/patient education: o Encourage the patient to take plenty of fluids and get enough rest. o Encourage the patient to cover her mouth when coughing to avoid the spread of the infection. o The patient’s caregiver should be advised not to administer aspirin and this increases the risks of developing Reye’s syndrome which a rare but deadly liver disease. o Ensure that the child is vaccinated yearly for influenza to prevent future infection. o Educate the family on the difference between antibiotics and antiviral agents and their indications especially for those available over the counter (Longe, 2018). o Educate the patient on the common side effects to expect when using the prescribed drugs and when to seek medical attention. For instance, some children taking oseltamivir may tend to experience sudden unusual changes in mood or behavior, and as such the parent should be informed to inform their physician in case of neurological and behavioral symptoms such as tremors, confusion, and hallucinations (McInerny, & American Academy of Pediatrics, 2017). · Disease Prevention at school: o Inquire more about your child’s school, college, or childcare program and how they handle instances of the flu outbreak and whether they offer flu vaccine on site (Longe, 2018). o Ensure that your child attends a school, childcare program or college that observes high hygiene especially since children are fond of touching objects and surfaces. They should be supplied with tissues, paper towels, soap, and alcohol-based had to rub in addition to disposable wipes on site (Hagan, Shaw, & Duncan, 2017). o Ensure that the school that your child attends have a perfect strategy on how to separate sick students and stuff to avoid spreading of infection.
A follow-up appointment with a detailed plan of f/u: The patient’s symptoms should resolve within two to three days. However, she should come back to the hospital after two weeks for assessment of the effectiveness of the prescribed care plan (McInerny, & American Academy of Pediatrics, 2017). However, in case of adverse effects or worsening of the symptoms, the patient’s caregiver should seek medical attention immediately. In the case of worsening symptoms, further lab tests will be ordered for further assessment. The patient vaccination status will also be checked and updated in case she missed any.

References

Drysdale, S. B., Green, C. A., & Sande, C. J. (January 01, 2016). Best practice in the prevention and management of pediatric respiratory syncytial virus infection. Therapeutic Advances in Infectious Disease, 3(2), 63-71.

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2017). Bright Futures guidelines for health supervision of infants, children, and adolescents: Pocket guide. American Academy of Pediatrics.

Longe, J. L. (2018). The Gale encyclopedia of nursing and allied health. Farmington Hills, MI: Gale.

McInerny, T. K., & American Academy of Pediatrics. (2017). American Academy of Pediatrics textbook of pediatric care. American Academy of Pediatrics.

Nishiyama, Masahiro, Morioka, Ichiro, Taniguchi-Ikeda, Mariko, Mori, Takeshi, Tomioka, Kazumi, Nakanishi, Keita, Fujimura, Junya, … Iijima, Kazumoto. (2018). Clinical features predicting group A streptococcal pharyngitis in a Japanese paediatric primary emergency medical centre. Sage Publications.