NSG6435 Week 8 SOAP

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School

South University, Savannah *

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Course

6435

Subject

Biology

Date

Feb 20, 2024

Type

docx

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Uploaded by DoctorSheepMaster1015

CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Student Name: Course: NSG6435 Patient Name: (Initials ONLY) C.W.. Date: 12/01/23 Time: 1500 Ethnicity: White Age: 6 Sex: F SUBJECTIVE (must complete this section) CC: Patient presents with father with complaint of "fever, sore throat and vomiting". HPI: C.W. is a 6-year-old infant female who is here with her father for an acute care visit. She is complaining of sore throat, vomiting, and fever for two days now. The patient is awake and alert and in no sign of acute distress. Her father states her highest temperature for the past two days was 102F, for which she was given Tylenol. She has decreased appetite and has vomited twice in the past 24 hours. She denies shortness of breath, cough, headache, congestion, or present abdominal pain. She is currently afebrile. Of note, she was treated for strep throat two weeks ago with a 7 day course of Augmentin. Medications: None Previous Medical History: Streptococcal pharyngitis Developmental History: No developmental concerns per father Allergies: NKA Medication Intolerances: NKDA Chronic Illnesses/Major traumas: None Immunizations: Up-to-date per Georgia Immunization Registry (GRITS Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: Hand hygiene emphasized. Nutrition/Diet: Adequate Exercise/Regimen: Active 1st grader Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: Father denies having any substances in the house. Safety Measures: Front-facing booster seat utilized Screening exams: None FAMILY HISTORY (must complete this section) M: HTN MGM: HTN MGF: Healthy F: HTH, anxiety PGM: Healthy PGF: Barrett's esophagus Social History: Lives with parents. In 1st grade at Richmond Hill Elementary School. REVIEW OF SYSTEMS (must complete this section) General: Admits fever and fatigue. Denies weight loss/gain. Cardiovascular: No cyanosis, swelling, or erythema of skin. Skin: No rash, itching, edema or abnormal skin tone. Respiratory: No cough, wheezing, dyspnea, tachypnea Eyes: No changes in vision. Gastrointestinal: Admits vomiting. Denies diarrhea, constipation, or abdominal pain Ears: No hearing loss or discharge Genitourinary/Gynecological: No frequency or hematuria Nose/Mouth/Throat: Admits sore throat. No nasal drainage or congestion. Musculoskeletal: No muscle weakness, joint swelling or stiffness. 06062023 Page 1 of 4

CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Breast: Negative for abnormalities. Neurological: No seizures, tremors or weakness. Heme/Lymph/Endo: Weight and appetite stable. No bruising or abnormal bleeding. No lymphadenopathy. Psychiatric: Denies difficulty sleeping, behavioral changes, hyperactivity. OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight: 57 lbs., 2 oz. Height: 47" BMI: 18.2 BP: 112/77 Temp : 100.0F Pulse: 132 Resp: 25 SPO2%: 97% General Appearance: Ill-appearing child, sitting upright, in no acute distress, accompanied by father. Skin: Warm, dry, clean and intact HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA, EOMI. No conjunctival redness or inflammation. Ears: Canals patent. Bilateral TMs normal color with distinct landmarks. Nose: Nasal mucosa pink; normal turbinates. Neck: Bilateral swollen anterior cervical lymph nodes. Oral mucosa moist and erythematous. Cardiovascular: S1, S2 with regular rate and rhythm. No murmur, gallop, rub, or click. Peripheral pulses normal and symmetric Respiratory: Lungs clear to auscultation bilaterally. Effort normal. Gastrointestinal: BS active in all 4 quadrants. Abdomen soft, non-tender. Breast: Visualized normal thoracic symmetry. Genitourinary : Deferred. Musculoskeletal: Full ROM seen in all 4 extremities. Neurological: Alert and oriented. Normal gait, tone, and strength. Psychiatric: Well-adjusted and appropriate during exam. Diagnostic Studies: Rapid strep swab ordered. Special Tests: None. DIAGNOSIS (must complete this section) 06062023 Page 2 of 4

CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Differential Diagnoses  Diagnosis, (ICD 10 code and reference): Viral pharyngitis (J02.9). Viral pharyngitis is regarded as the most common cause of a sore throat. It is often accompanied by fatigue, hoarseness, and a low-grade fever, for which the patient is positive for. Vomiting is atypical of viral pharyngitis (Bosmia & Willig, 2023).  Diagnosis, (ICD 10 code and reference): Gastro- esophageal reflux disease, unspecified (K21.9). GERD can present similarly to strep throat, as acid reflux will cause a sore throat. Additional symptoms include a persistent cough, difficulty swallowing, and pain in the chest (Children with Reflux, 2022). The patient is negative for these symptoms .  Diagnosis, (ICD 10 code and reference): Influenza, unspecified (J11.1). Strep throat is a bacterial infection, unlike influenza. Strep does not typically include other cold/flu-like symptoms, such as a runny nose or cough (Ashurst & Edgerley-Gibb, 2023. Patient negative for runny nose, cough, or congestion. Diagnosis  Presumptive diagnosis (ICD 10 code and reference): Streptococcal pharyngitis (J02.0). According to the Infectious Disease Society of America (IDSA), a rapid antigen detection test (RADT) is the first-line measure to assist the physician in the diagnosis of GAS pharyngitis. Furthermore, positive tests do not require a throat culture due to the high specificity of the RADT. However, in the pediatric setting, a negative RADT should be followed by a throat culture (Ashurst & Edgerley-Gibb, 2023). Plan/Therapeutics: 1) Streptococcal pharyngitis (J02.0). Positive rapid strep swab. Rx. cefdinir 250 mg/5 ml suspension; 3.5 ml twice a day by oral route for 7 days. An alternative antibiotic, such as cefdinir, is indicated in cases of recurrent strep where a previous medication has failed. Cefdinir is a 3rd generation cephalosporin bactericidal antibiotic. It is active against both gram-negative and gram-positive organisms (Arumugham, Gujarathi, & Cascella, 2023). 2) Acute pharyngitis, unspecified (J02.9). Rapid strep swab obtained. Diagnostics: Strep swab (+) 06062023 Page 3 of 4

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CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Education Provided: Educated on medication and importance of finishing course of antibiotic. Discussed importance of good hand hygiene and respiratory etiquette (covering cough and sneeze) to reduce the spread of a group A strep infection. The father was instructed to supply a new toothbrush and discard the contaminated one. Lastly, the patient should stay home from school until she is afebrile at least 12–24 hours after starting appropriate antibiotic therapy (Centers for Disease Control and Prevention, 2022). Understanding of teaching verbalized by father. References: Arumugham, V.B., Gujarathi, R., and Cascella, M. (2023, June 4). Third-Generation Cephalosporins. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK549881/ Ashurst, J.V. & Edgerley-Gibb, L. (2023, May 1). Streptococcal Pharyngitis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK525997/ Bosmia, A. & Willig, J. (2023, February 10). Streptococcal pharyngitis. Visualdx. https://www.visualdx.com/visualdx/diagnosis/streptococcal+pharyngitis Centers for Disease Control and Prevention. (2022, June 27). Pharyngitis (Strep Throat). https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html#diagnosis Children with Reflux. (2022). Canadian Society of Intestinal Research. https://badgut.org/information-centre/a-z- digestive-topics/children-with-reflux/ 06062023 Page 4 of 4