Soap Note Week Two Peds
For this assignment, you are to complete a clinical case – narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 – 3: You decided on Angina after reading the clinical case scenario (Step 1) Review of Symptoms (list of classic symptoms): CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone GI: indigestion, heartburn, nausea, cramping Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth Resp: shortness of breath Musculo: weakness
Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4: You determined the patient has Angina in Step 1 Physical Examination (list of classic exam findings): CV: RRR, murmur grade 1/4 Resp: diminished breath sounds left lower lobe
Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following: a) Medications (include the dosage in mg/kg, frequency, route, and the number of days) b) Laboratory tests ordered (include why ordered and what the results of the test may indicate) c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate) d) Vaccines administered this visit & vaccine administration forms given, e) Non-pharmacological treatments f) Patient/Family education including preventive care g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) h) Follow-up appointment with a detailed plan of f/u
CLINICAL CASE SCENARIO
A 5-year-old male patient presents to your clinic for ear pain. His mother reports he was in good spirits and energetic until about 5 days ago when he developed an upper respiratory infection (URI) consisting of clear nasal discharge and cough. The mother reports that he has been lethargic and stopped drinking fluids about 48 hours before he developed a temperature of 102.1°F and started complaining that his right ear hurt. The mother denies nausea, vomiting, diarrhea, headache, or change in urine output. The mother reports that the patient’s sleep was interrupted due to his complaints of right ear pain. She noticed that he tugged at his right ear frequently while remaining minimally interested in playing with his toys earlier in the day. Today, his vitals are as follows: weight 40.5 lbs, height 43.0 inches, BP 100/70, HR 100, RR 26, and Temperature is 102F.
Diagnosis: Acute Otitis Media
As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:
FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:
DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.
SUBJECTIVE (S): Describes what the patient reports about their condition. For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.
Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies. Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc… SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.
Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)
HRB (Health-related behaviors): ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).
OBJECTIVE: Physical findings you observe or find on the exam. 1. Age, gender, general appearance 2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart 3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has) 4. Lab Section – what results do you have? 5. Studies/Radiology/Pap Results Section – what results do you have?
RISK FACTORS: List risk factors for the acute and chronic conditions
ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.
You are to also list any chronic conditions with the ICD-10 codes.
NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan
TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.
Example:
1. HTN a) Vaccines administered this visit & vaccine administration forms given, b) Medication-include dosage amounts and mg/kg for drug and number of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family education including preventive care
2. HLD a) Vaccines administered this visit & vaccine administration forms given, b) Medication-include dosage amounts and mg/kg for drug and number of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family education including preventive care Also discussed: g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section) Return to the clinic: h) Follow-up appointment with a detailed plan for f/u and any referrals