Expert answer:SOAP note for 2month infant, well check found with
Solved by verified expert:please do a focus problem for a 2month old baby with VSD, make sure the chief compaints, and ROS, physical exam relates to VSD clinical findings. Please include three differential diagnose with ICD code include and rational in the clinical findings that lead to the differential diagnose, the primary diagnose being ventricular septal defect (VSD). please also include the treatment plan for the 2month old baby, and be sure to use evidence-based guidelines. Only use evidence based articles not later than 2012. Treatment plan includes, medication if needed, anticipatory guides for parents. and non-pharmacological treatment to help with symptoms. Also be sure to include what diagnostice test this patient will need, don’t forget to references. It should be in APA format. please be very detail in your assements and treatment plans.please see the templet provided, you don’t have to fill out all the parts of this templet only waht is pertinent finding during a office on a 2month old child with VSD. please use the uploaded template, some of the information is already fill in, just need to fill in the clinical fings of a VSD patient, 3 differentials diagnose with the ICD code including the rational of what you found in the physical exam or health history that brought you to that conclusion. And finally the Treatment plan, with evidence based guidelines.
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Pediatric SOAP Note
Name: Alex
Date: 10/ 31/17
Sex: male
Age/DOB/Place of Birth: 2 months/ Sarasota
SUBJECTIVE
Historian:
Present Concerns/CC:
Patient present with mom, for weight check, and well check. “Alex has had a hard time latching on, he
seems as though he can breath and has to let go”
Child Profile: (Sexual
Patient lives with both parents, mom is at with baby, for now. Has one older brother. Patient
has reached appropriated development milestones, can “coo” he is trying to smile.
HPI: (must include all components)
Mom reports he been sounding congestive when he breath, and she notice he is always sweaty. Bowel
movement has been normal but very little. He doesn’t seem like he wants to eat, and sleep a lot. Baby is
not gaining weight between 20-30g /per.
Medications: (List with reason for med )
none
PMH: Mother had no complication with pregnancy or birth. She had a vaginal delivery 39 weeks. Mom
is breastfeeding.
Allergies: No Known allergy
Medication Intolerances: None
Chronic Illnesses/Major traumas: no major trauma, ear infection over the past month.
Hospitalizations/Surgeries: none Immunizations: up to date, he will be given vaccines at this visit:
o Hep B
o DTaP:
Hb
o IPV:
Family History (Please identify all immediate family)
Father has no medical conditions. Mother has high cholesterol. Older brother is healthy.
Social History Education level, occupational history, current living situation/partner/marital status,
substance use/abuse, ETOH, tobacco, and marijuana. Safety status
Parents are married. Mom denies any drug or tobacco use. Both parent works full time, but mom
is off right now.
ROS
General- reports sleepy, and not interested in
feeding.
Skin
denies any lesions, eczema, bruising, or trauma.
Cardiovascular
Denies wheezing or fast heart rate.
Respiratory
Reports no coughing or wheezing, but seem to have
to can’t catch his breath when feeding.
Pediatric SOAP Note
Eyes
Denies any vision change
Ears
Denies any discharge
Nose/Mouth/Throat
denies tenderness over the frontal or maxillary.
No discharge or polyps. Normal with no
redness.
Breast
Gastrointestinal
Denies diarrhea, or constipation.
Genitourinary/Gynecological
Report normal, seem regular, but small amount
Musculoskeletal
Denies any abnormal muscle movement
Neurological
Denies any involuntary movement,
Not exam
Heme/Lymph/Endo
Psychiatric- denies crying any more than more
No mass, or lymphadenopathy. No enlargement
of lymph nodes.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight
Temp
BP
7.7lbs
98.4
78/56
Height
Pulse
Resp
23inches
190
48
General Appearance and parent‐child interaction. Moves all extremities well, sleeping in mom’s arm.
Skin; normal warm dry, no lesion, or scaling. No rashes on face, arms, or legs.
HEENT- head has no lump or lesion, eyes: No strabismus, red reflect seen, ear: Hearing is intact.
External is red. on otoscopic exam tympanic membranes and inner ear are
red, fluid is also noted behind the tympanic membrane. Nose; no tenderness over the frontal or maxillary.
No discharge or polyps. Normal with no redness. MOUTH: no tonsillar hypertrophy, no dental issues.
Good dental hygiene.
Cardiovascular:
Mummer, and S3 is heard. Cap refill more than 3 seconds. And pulse is diminish on femoral.
Respiratory: Clear to auscultation bilaterally without wheezes, rales, or rhonchi.
Gastrointestinal
Bowel sounds are active, no scar or striate visualized. No tenderness throughout, no mass palpate.
Breast: no mass, or tenderness, no rash or lesion
Genitourinary: No bladder distention. No redness or diaper rash noted.
Pediatric SOAP Note
Musculoskeletal: full range of motion in all extremities. joint stability normal in all extremities.
Neurological: Communication ability within normal limits, attention and concentration normal. Sensation
intact to light touch. Can follow face
Psychiatric: Cooperative. Patient appears to be irritable.
In-house Lab Tests – document tests (results or pending)
– No diagnostic tests were ordered in the clinic
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
No concern as reported by mom in past well check. Not here for well check.
Diagnosis
✓ J06.9 Acute upper respiratory infection. [Patient is having ear pain and there is
fluid noted behind the patient’s ear. Also has low grade temp. This could be an
early sign of a URI. Refuting data: There are no respiratory symptoms, such as
coughing noted]
✓ H60.22 Acute Otitis Externa. [Patient is pulling his left ear lobe and according to
the patient’s mother he has been more irritable lately. Refuting data: The ear is
red and inflamed into the canal. There is also fluid noted behind the tympanic
membrane.]
✓ H66.9: Otitis media, unspecified. [Mother reports that patient has been pulling at
his left ear and crying more than usual, which is a sign of pain in a pediatric
patient. She has also been running a low-grade fever. Upon assessment, the ear
canal and tympanic membrane are both red]
PLAN including education
✓
✓
No Laboratory tests ordered
For this patient who had a temperature of 102.4 F in the office, and mom reports
she been running a fever for two days prior, I would be comfortable prescribing
Amoxicillin 400mg/kg/5ml, dose of 80mg/kg/ml BID and the child weight is
12.7kg, which come out to 6.5ml every 12hours. For 10days.
✓ Reinforce the importance of completing the entire dose of antibiotics, regardless
of if the patient begins to feel
✓ better after just a few days. If he misses a dose, take the missed dose immediately.
✓
✓
Patient education: Smoking cessation of family members who are often around the
child is very important. When a child has multiple episodes of AOM, it is often
related to smoking in the home, avoidance of smoker is very important for this
child. Avoid cleaning the patient’s ear with a Q-tip.
✓ Patient need to contact office if continued fever or no improvement in symptoms
in 48 hours.
✓ (Cash 800)
✓ Follow-up appointment in 2 weeks. (Bina, 2015)
Pediatric SOAP Note
References
Bina, A. (2015). Differential Diagnosis of Acute Otitis Media (AOM) from Secretory Otitis Media (SOM)
through Tympanometry, Audiometry and Diapasonic Tests: Reporting two Cases with Acute Otitis
Media. Journal of Otolaryngology-ENT Research, 2(3). doi:10.15406/joentr.2015.02.00027
Burns, J. B., & Rich, K. L. (2015). Philosophies and theories for advanced nursing practice.
(2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Cash, Jill C., MSN, APN, FNP-BC. Family practice guidelines, Third Edition, 3rd Edition. Springer
Publishing Company, 20140210. VitalBook file.
…
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