Soap note

Pediatric SOAP Note table class=’wp-block-table’tbodytrtdName: P. L/tdtdDate: 03/09/2018/td/trtrtdSex: Male/tdtdAge/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba/td/trtrtdSUBJECTIVE/td/trtrtdHistorian: emMother and patient/emPresent Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”/td/trtrtdChild Profile:Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car./td/trtrtdHPI:Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.Med/td/tr/tbody/table table class=’wp-block-table’tbodytrtdMedications: He is not currently taking any medications. Has taken Excedrin Extra Strength 1 tab orally by mouth as needed for headache in the past./td/tr/tbody/table table class=’wp-block-table’tbodytrtdPMHX:Allergies: emNKA/emMedication Intolerances: emNone/emChronic Illnesses/Major traumas: NoneHospitalizations/Surgeries: NoneImmunizations: emUp to date/em/td/trtrtdFamily HistoryemMother and father alive. /emMother has history of GERD and father suffers from HTN. Paternal grandparents are deceased. Both of old age. Maternal grandfather and maternal grandmother are alive, and they only suffer from GERD and OA./td/trtrtdSocial HistoryPatient is only child and lives with his parents. He is currently on high school. He is enrolled in a dual program where he is taking college classes in advance. He spends most of his time studying. He has applied to various universities and expects to obtain full scholarship. Mother denies guns at home or exposure to second hand smoking. Patient does not work because his school requires him to spend a great amount of time to it. Both parents are very supportive of patient. Patient denies being sexually active and denies having a girlfriend. He has a group of close friends./td/trtrtdROS/td/trtrtdGeneralDenies fever, weight loss or generalized weakness/tdtdCardiovascularDenies chest discomfort, palpitations, or chest pressure/td/trtrtdSkinDenies open wounds, rash, or hives/tdtdRespiratoryDenies for hemoptysis, tachypnea, dyspnea or cough/td/trtrtdEyesDenies blurred vision, diplopia, and sense of curtain falling or intolerance of light. Positive for reading glasses./tdtdGastrointestinalDenies nausea, vomiting, lack of appetite or changes in bowel habits/td/trtrtdEarsDenies ear pain, tinnitus, or discharge/tdtdGenitourinary/GynecologicalDenies changes in urine color, dysuria, or hematuria/td/trtrtdNose/Mouth/ThroatDenies mouth sores, epistaxis, nasal congestion, or difficulty swallowing/tdtdMusculoskeletalDenies joint swelling, stiffness, or pain/td/trtrtdBreastNot examined/tdtdNeurologicalReport headaches x 3 weeks. Negative for paralysis, tremors, seizures, speech difficulty or confusion/td/trtrtdHeme/Lymph/EndoDenies fatigue, anemia, cold/heat intolerance or enlarged lymph nodes/tdtdPsychiatricDenies problems falling asleep or staying asleep, depression or suicidal ideations. Positive for high levels of stress and some anxiety/td/trtrtd/td/trtrtdWeight164 lbs/tdtdTemp 98.7/tdtdBP 122/63/td/trtrtdHeight em5’7”/em/tdtdPulse72/tdtdResp: 18/td/trtrtdGeneral Appearance and parent‐child interaction:Cooperative and calm patient accompanied by his mother. Both with clear and appropriate speech and language/td/trtrtdSkinSkin is intact. Good turgor. Capillary refill 2 seconds/td/trtrtdHEENTHead: Normocephalic, atraumatic. Eyes: symmetric. Normal eye lashes and lids, Clear conjunctiva. Visual fields full to confrontation. No ptosis. Pupils PERRLA. Ears: No trauma or drainage. Nontender tragus. Mouth: Intact gag reflex. Nose: Patent nares with midline septum. Neck: supple with no JVD and full ROM./td/trtrtdCardiovascularNormal heart rate and sounds. Pedal pulses 2+ bil. No cyanosis, clubbing or edema of the lower extremities/td/trtrtdRespiratoryLung fields clear to auscultation. Respiratory rate within normal parameter. Symmetric chest wall expansion. No use of accessory muscles observed./td/trtrtdGastrointestinalAbdomen is flat with normoactive bowel sounds in all quadrants. Exam negative for tenderness or guarding/td/trtrtdBreastNot examined during this visit/td/trtrtdGenitourinaryNo bladder distention or CVA tenderness/td/trtrtdMusculoskeletalPatient with full ROM. Normal spinal curvature and good head control. No joint deformities or inflammation seen./td/trtrtdNeurologicalExtremities movable 5/5 strength. Intact coordination with finger to nose test. Intact sensation to light and deep touch. Reflexes 2 + throughout. Romberg test negative./td/trtrtdPsychiatricPatient with adequate engagement in conversation, normal mood, no indications of depression at this time/td/trtrtdIn-house Lab Tests – document tests (results or pending)MRI of the brain and cervical spine: Exam to be completed in an outpatient imagingcenter as soon as possible/td/trtrtdDiagnosis/td/trtrtd/td/trtrtdPrimary Diagnosis:· Tension headache (G44.209): This diagnosis was selected based on physical examination and history of recent exposure to higher levels of stress. Pending MRI results to rule out other causes if any.· Plan including education· MRI scheduled for next day.· Start Midrin 325 mg take 1 cap every 4 hours as needed for severe headache. Do not exceed 8 capsules per day.· Motrin 800 mg 1 tablet every 8 hours as needed for pain· Follow up in the office for tests resultsEducation· Patient and mother educated about tension headaches and that they could be related to high stress levels. However, further testing was ordered to rule out other possible causes. Patient verbalized understanding and agreed to additional test to rule out more serious causesEducated to keep a log with frequency of headachesInstructed to take medications as prescribed and do not exceed recommended dosage.Educated about the importance of a life –school balance, participate in physical activities, getting sufficient sleep and proper nutritionUse relaxation and deep breathing techniques and take frequent brakes while using computer or other electronic devices (Donaldson, 2016)/td/trtrtd/td/tr/tbody/table Differential diagnosis – 1. Tension headache (G44.209): Tension headaches arediv style #button { background-color: #F05A1A; border: 5px; border-radius: 5px; color: white; padding: 5px 5px; text-align: center; text-decoration: none; display: inline-block; font-size: 13px; margin: 4px 2px; cursor: pointer; } /style div class=’alert alert-success’ h3Save your time – order a paper!/h3 p style=’font-size: 16px;’Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlines a href=’/order’ id=’button’Order Paper Now/a /div/div often described as dull pain on the back of the head or in forehead. They are also called stress headaches and they are often the result to high level of stress (Donaldson, 2016). 2. Brain tumor (C71.9): While many cases are asymptomatic, a new onset of headache can warrant further testing to rule out this diagnosis. According to Prosad Paul, Perrow & Webster (2014), patients with brain tumors can have persistent headaches, problems with coordination, dizziness, fatigue or weakness. This patient does not present other symptoms; however, this differential diagnosis is a must no miss and therefore is included for this patient. 3. Herniated cervical disk (M50.10): Although not very common, serious cervical pathologies such as herniated disk can cause headaches (Donaldson, 2016). References: Donaldson, S. (2016). Tension Headaches: Psychological Factors. Biofeedback, 44(1), 15-18. doi:10.5298/1081-5937-44.1.06 Prosad Paul, S., Perrow, R., & Webster, M. A. (2014). Brain tumours in children: reducing time to diagnosis. Emergency Nurse, 22(1), 32-36.