Chamberlain College of Nursing - NR 509DR_SOAP RESPIRATORY_Week 6. SOAP RESPIRATORY_Wk 6.

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SOAP Note Template Initials: D.R> Age: 8 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies 127 cm [stated by pt] 40.8 kg [stated by patient] 120/ 76 100 28 37.2C 96 3/10 Medica... tion: NDA Food: NA Environment: NA History of Present Illness (HPI) Chief Complaint (CC) “I’ve been feeling sick. I have been coughing a lot,” R ear pain CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset “every few minutes,” worsening at night Location Throat, R ear Duration Cough X 5 days; R ear pain/sore throat x 1 day Characteristics Cough: productive w/ clear sputum (“gurgly and watery”). Prevents pt from sleeping. Aggravating Factors No known factors Relieving Factors OTC cough medicine. Treatment OTC cough medicine. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use OTC cough medicine; name unknown unknown unknown This a.m. Cough OTC Dinosaur gummy vitamins 2 gummies Daily Unknown Supplement . Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, S: Subjective Information the patient or patient representative told youhospitalizations, and surgeries. Depending on the CC, more info may be needed. No influenza vaccine in previous 12 months Hep A series completed at 15 months Heb B series completed at 6 months Pneumococcal series completed at 15 months DTap series completed at 6 yrs MMR series completed at 6 yrs Varicella series complete at 6 yrs Polio series completed at 6 yrs No surgical hx No prior hospitalizations Pneumonia last year (seen/treated in urgent care) Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. 3rd grade student – missed 2 weeks of school d/t pneumonia Lives with both parents and grandmother English primary language; Spanish secondary Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother: DM Type 2, HTN, hypercholesteremia, spinal stenosis, obesity Father: Smoker, HTN, hypercholesteremia, asthma as child Maternal Grandmother: DM Type 2, HTN Maternal Grandfather: Died in MVC (52 yo) Paternal Grandfather: No known hx Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☒Fatigue Difficulty sleeping d/t cough ☐Itching . ☐Diplopia . ☒Earache 3/10 pain ☐Tinnitus here ☐Hoarseness here to .☐Weakness . ☐Fever/Chills . ☐Weight Gain . ☐Weight Loss . ☒Trouble Sleeping d/t cough ☐Night Sweats . ☐Other: . ☐Rashes . ☐Nail Changes Click or tap . ☐Skin Color Changes . ☐Other: . ☐Eye Pain . ☐Eye redness Click or tap . ☐Vision changes Click or tap . ☐Photophobia Click or tap . ☐Eye discharge Click or tap . to . ☐Epistaxis . ☐Vertigo here to . ☐Hearing Changes Click or tap . ☐Oral Ulcers here to . ☒Sore Throat here to . ☐Congestion here to . ☒Rhinorrhea clear and watery phlegm ☐Other: . Respiratory Neuro Cardiovascular ☒Cough Productive, clear ☐Hemoptysis . ☐Dyspnea . ☐Wheezing . ☐Pain on Inspiration here to . ☒Sputum Production White Small Thin ☐Other: . ☐Syncope or Lightheadedness . ☐Headache here to . ☐Numbness here to . ☐Tingling . ☐Sensation Changes . ☐Speech Deficits . ☐Other: . ☐Chest pain . ☐SOB . ☐Exercise Intolerance here to . ☐Orthopnea . ☐Edema . ☐Murmurs . ☐Palpitations . ☐Faintness here to . ☐OC Changes . ☐Claudications . ☐PND . ☐Other: . MSK GI GU PSYCH ☐Pain ☐Nausea/Vomiting ☐Urgency ☐Stress . ☐Stiffness . ☐Crepitus . ☐Swelling . ☐Limited ROM . ☐Redness . ☐Misalignment . ☐Other: . . ☐Dysphasia . ☐Diarrhea . ☐Appetite Change . ☐Heartburn . ☐Blood in Stool . ☐Abdominal Pain . ☐Excessive Flatus . ☐Food Intolerance . ☐Rectal Bleeding . ☐Other: . . ☐Dysuria . ☐Burning . ☐Hematuria here to . ☐Polyuria . ☐Nocturia . ☐Incontinence . ☐Other: . . ☐Anxiety . ☐Depression here to . ☐Suicidal/Homicidal Ideation . ☐Memory Deficits . ☐Mood Changes . ☐Trouble Concentrating Click or tap . ☐Other: . GYN ☐Rash . ☐Discharge . ☐Itching . ☐Irregular Menses . ☐Dysmenorrhea . ☐Foul Odor . ☐Amenorrhea . ☐LMP: . ☐Contraception . ☐Other:. Body System Positive Findings Negative Findings O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.General . Danny appears to be unwell. Presents with persistent cough during assessment. This is a well-developed, pleasant, well nourished, in no apparent distress. Alert and Oriented x3, normal mood and affect, Ambulates without difficulty. Skin . . Normal color with no rashes, no lesions, and no evidence of cellulitis. Negative lymphadenopathy. HEENT . R auditory canal and TM erythemic; R-sided cervical lymphnodes palpable/tender. Erythemic tonsil. Oropharynx cobblestoning and erythemic.. Clear drainage from nose.Tonsils erythemic. Conjunctiva pink, moist, clear. Sclera clear, white. No palpable lymphnodes axillay, supraclavicular bilaterally, L-sided cervical lymphnodes not palpable. Septum midline, turbinates bilaterally pink, moist. Neck symmetric; no abnormal findings. No tenderness w/palpation of neck. Buccal/oral mucosa pink/moist. No post-nasald drip visualized. Respiratory . Frequent, productive cough. Symmetrical expansion of chest upon inspiration/expiration. Breath sounds found in all areas. Pt denies SOB. Bronchoscopy negative. Fremitus equal over all chest areas. No Neuro . . Oriented x3. clear speech, face symmetric Normal LOC. Memory intact. Attention span, general knowledge, judgment, memory, vocabulary, articulations. No headaches. Cardiovascular . . All 5 heart sounds presents; no S3/S4 sounds present. Musculoskeletal . . No abnormal findings Gastrointestinal . . No abnormal findings. Genitourinary . Unable to assess.Problem List 1. Sore throat 6 Rhinorrhea 11 . 2 Productive cough 7 12 . 3 Right ear pain 8 . 13 . 4 Fatigue 9 . 14 . 5 R cervical lymphnode enlargement 10 . 15 . Diagnostics: List tests you will order this visit Test Rationale/Citation . Psychiatric . . Appropriate for age of patient and situation. Gynecological . . Unable to assess. Diagnosis ICD-10 Code Pertinent Findings Pharyngitis J02.9 Cough, ear pain, sore throat, rhinorrhea, cobblestoning Acute otitis media, R ear H65.01 R ear pain, erythemic auditory canal and TM. Upper Respiratory Infection J06.9 CC cough x 5 days, sore throat, ear pain. P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in- citation for each intervention. A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.None at this time. Strep test, flu swab is not indicated for rhinorrhea and cough with absence of fever. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Acetaminophen 10-15mg/kg PO q4-6 hours 5 days or earlier with F/U Use for symptomatic throat and ear pain/antipyretic (Epocrates, 2019) Ibuprofen 5-10mg/kg PO q6-8 hours Max: 40mg/kg/day 5 days or earlier with F/U Use for symptomatic throat and ear pain/antipyretic (Epocrates, 2019) Referral/Consults: None at this time. Rationale/Citation Symptoms should resolve on own. Education: - Abx not appropriate for viral infections. -If parent does not want to administer cough medicine, honey can be used as a substitute. -Warm salt water gargle can be used to relieve sore throat: Combine ¼ - ½ tsp salt in one cup of warm water; gargle and spit. Conduct good personal hygiene: -Cover mouth when coughing -Wash hands -Do not share utensils/glasses/toothbrushes Seek medical attention if Danny acquires a fever equal or greater than 101.1*; condition worsens; he stops/refuses drinking fluids. Rationale/Citation -According to Wald (2019), use of antibiotics have negatively impacted the efficacy of abx on bacterial infections. Generally URI’s resolve by themselves in approx. -Optimal method to prevent the spread of germs is by hand washing; cover mouth when coughing to prevent spreading illness (Pappas, 2019). Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Return to office if S/S last longer than 10 days for further evaluation. Rationale/Citation Viral pharyngitis generally resolves on its own between 4-10 days (Piltcher et al., 2018)References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Acetaminophen. (2019). In Epocrates Plus for Apple iOS (Version 19.10.1) [Mobile application software]. Retrieved from http:itunes.apple.com Ibuprofen. (2019). In Epocrates Plus for Apple iOS (Version 19.10.1) [Mobile application software]. Retrieved from http:itunes.apple.com Pappas, D. (2019). The common cold in children: Clinical features and diagnosis. Retrieved from https://www.uptodate.com/contents/the - common-col-in-children-clinical-features-anddiagnosis?search=acute%20viral%20upper%20respiratory%20infection&source=search_result&selectedTitle=2~&usage_type=default&display_ rank=2#H1 Piltcher, O., Kosugi, E., Sakano, E., Mion, O., Testa, J., Romano, F., Tamashiro, E. (2018). How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel. Brazilian Journal of Otorhinolaryngology, 84(3), 265-279. Wald, E. (2019). Patient education: Sore throat in children (Beyond the Basics). Retrieved from UpToDate: https://www.uptodate.com/comtents/sore-throat-in-children-beyone-thebasics?search=acute%20pharyngitis%20children&topicRef=6457&source=see_link#H13 . [Show More]

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