Tension headache in a 13 years old adolescent

Discusion topic: SOAP note about

Requirements

· The discussion must address the topic

· Rationale must be provided

· Use at least 600 words (no included 1st page or references in the 600 words)

· May use examples from your nursing practice

· Formatted and cited in current APA 7

· Use 3 academic sources, not older than 5 years. Not Websites are allowed.

· Plagiarism is NOT permitted

Demographic Information:

Encounter Date:

Patient initials:

Age:

Race:

Gender:

Insurance:

Information Source:

SUBJECTIVE

Chief complaint:

History of present illness (HPI):

Allergies:

Medication History:

Family History:

Past medical History (PMH)

Immunization status:

Developmental stage:

Hospitalization:

History of mental illness/personality disorders:

Physical trauma/falls:

Surgeries:

Exercise:

Diet:

Social History:

Last annual physical exam:

REVIEW OF SYSTEMS:

Systemic:

HEENT:

Head:

Neck:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Mental:

Integumentary:

OBJECTIVE:

Physical Exam

Vitals Signs:

General appearance:

Skin:

Lymph nodes

HEENT:

Head:

Face:

Eyes:

Ears:

Nose:

Mouth:

Throat

Neck

Chest/Lungs

Cardiovascular:

Abdomen:

Genitals/Urinary:

Musculoskeletal

Neurologic

ASSESSMENT

Diagnosis

Differential diagnosis

PLAN

labs /Diagnostic test ordered

Pharmacological treatment:

Non-pharmacological measures:

Education:

Referral/Follow up:

References

10

SOAP Note # 1 Acute Otitis Media

Demographic Information:

Encounter Date:

Patient initials: A.L.

Age: 12 y/o

Race: Hispanic

Gender: Male

Insurance: PPO

Information Source: Given by patient’s mother

SUBJECTIVE

Chief complaint: “My child has Left ear pain for 2 days”

History of present illness (HPI): A.L is an 12-year-old Hispanic male healthy patient, who came to the office today, complaining of left ear pain (rated 5-10) for two days as per her mother referred with the previous history of the patient started with an Upper Respiratory infection (URI) symptoms such as nasal secretion and nasal congestion seven days ago after the nasal discharge was yellow, little appetite and nausea in the child began to complain of earache that has been alleviated with drops of warm oil and today starts with a high fever that was treated with Tylenol, her mother notices the sleepy and malaise child, denies vomiting, dizziness or other symptoms

Allergies: NKA.

Medication History: Tylenol 500 mg for pain or fever

Family History:

Mother Alive: 36 y/o / Healthy

Father Alive: 45 y/o/ Healthy

1Sister Alive 16 Healthy

Negative Hx for Cancer, Dead for CV event, Genetical disease

Past medical History (PMH): Negative for Chronic Disease. Unremarkable. Delivered at 39.2 W2D. Spontaneous vaginal delivery was uneventful. Normal birth weight, Apgar score 8/9. DC two days after delivery

Immunization status: Up to date on all vaccines.
: DTAP (5 doses); Hib (4 doses) IPV (4 doses); MMR (2dose); VAR (2 doses); HBV (3 doses); PCV (4 doses); RV (3 doses); HAV (2 doses); Influenza vaccine received on 12/19/2019

Developmental stage: Normal development according to his age.

Hospitalization: No previous hospitalization.

History of mental illness/personality disorders: None.

Physical trauma/falls: No reported during the last twelve months.

Surgeries: No previous history

Exercise: No engage in any regular exercise’s regimen/ only school sport activities (Hold now due to COVID 19 pandemic)

Diet: Regular and well balanced.

Social History: Patient
lives with his married parents in an apartment.
Normal familiar dynamic, he has a healthy sister 16 y/o. He is a middle school student with good/normal development and social interaction Denied smoke, alcohol intake and use or recreational drugs.
, No second-hand smoking exposure. Denies being sexually active

Last annual physical exam: 12/19/2019 (Normal)

REVIEW OF SYSTEMS:

Systemic: Patient complaint
fever about 102.2. He denied change in appetite; tired, weakness or sleep disorder.

HEENT. Head: Patient complaint left ear pain 5/ 10, No history of trauma, no complaining of headache. No sinus pain or any other facial pain is stated.

Neck: Denies pain or stiffness. No swollen glands in the neck.
Eyes: Denies blurring vision, double vision, redness or eye discharge. Oto-laryngeal
: Complains left ear pain , yellow nose discharge and congestion , denies nasal bleeding. Denies bleeding gums. No hoarseness. last dental exam was 6 months ago, no cavities

Cardiovascular: Denies chest pain, palpitation or edema on the lower extremities.

Respiratory: Denies shortness of breath, cough or wheeze. No complaints of chest congestion.

Gastrointestinal: Denied appetite problems. Denied abdominal pain, no food intolerances, no nausea or vomiting, no constipation. Last bowel movement: 07/20/2020

Genitourinary: Denies changes in urinary habits, normal urinary frequency. Denies history of kidney stones, flank pain, cloudy urine or bad smell, denies being sexually active.

Musculoskeletal: Denied joint pain or stiffness.

Neurological: Denied drowsiness, or focal weakness, no syncope, no seizures, no visual or speech disturbances, no impaired mobility, no memory deficit.

Mental: No anxiety, no depression, no memory problems, denied trouble concentrating.

Integumentary: Denies pruritus, bruises or rash.

OBJECTIVE:

Physical Exam

Vitals Signs: Temp (Axillary): 102.20F. BP-sitting L: 108/66 mmHg (BP cuff size: Regular). Pulse Rate-Sitting: 92 bpm. (Regular rhythm). RR: 18 per min. Height 4”6”, Weight: 85lbs. BMI: 20.5 Kg/m2 (normal) 50 percentile. Oxygen Saturation: 99 %. Pain Scale/Rate: 5/10.

General appearance: Patient normal percentile according height and weight, properly dressed, speech clear and appropriate, cooperative to the interview, alert, oriented in place, person, time. Discomfort due to the pain is reflected in his face and posture. Well hydrated, well nourished

Skin: Skin normal turgor, no bruises, and no changes in moles. No visible or palpable lesions or rashes, no cyanosis.

Lymph nodes: Left periauricular adenitis, no palpable cervical, supraclavicular, axillary or inguinal nodes.

HEENT:

Head: Normocephalic, normal face symmetry. Scalp with no lesions, no tenderness. Hair distribution according to her age. Temporomandibular joint full ROM without clicks o pain bilaterally. No frontal or maxillary sinus tenderness.

Face: Symmetric facial expression, no deformities, tenderness to palpation over maxillary sinuses, no periorbital edema, no changes in color pigmentation, no involuntary movements.

Eyes: EOMs intact. Brows and lashes normal configuration, no edema, White sclera, no lesions; PERRLA.

Ears: Right ear with normal appearance, no erythema, tympanic membrane pearly grey, translucent with no bulging, no discharge. Left tympanic membrane erythematous and bulging with diminished bony landmarks. No purulent drainage observed
.  Painful to palpation of mastoid bone. 
Nose: Bilateral nares patent pink coloration without rhinorrhea; no edema of the turbinate found. Septum midline

Mouth: pink, moist mucous membranes. No missing or decayed teeth.
Throat: Pink normal oropharynx erythematous, without tonsillar edema or exudate; uvula midline.

Neck: Flexible; denied pain. Thyroid not visible or palpable. No carotid bruits and no jugular vein distention.

Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sounds are clear, no wheezing, rhonchi, or crackle, no prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted, no axillary lymphadenopathies.

Cardiovascular: S1 and S2 regular rate and rhythm with no splitting. Carotid with no bruits. No JVD. No thrills. No rubs. Peripheral pulses present in all extremities. Capillary refill less than 3 seconds. No edema.

Abdomen: Skin without lesions, or rashes. Abdomen flat and symmetric with no lumps or bulges. Bowel sounds presents in the 4 quadrants. Percussion reveals tympany over all quadrants. No tenderness no guarding in any quadrant with palpation. No palpable masses or hepatosplenomegaly.

Genitals/Urinary: Penis circumcised without lesions, urethral meatus normal location without discharge, testis and epididymis with normal size without masses, scrotum without lesions. Tanner Stage 2.

Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal deficit, no joint inflammation or deformities noted.

Neurologic: Patient alert and oriented in person, time and place, cranial nerves II-XII intact. No focal motor or sensory deficits. Coordination, sensation, and reflexes are intact.

ASSESSMENT

Acute Otitis Media, Left Ear (H65.02): is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute Otitis media is usually a complication of Eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. (Domino, Baldor, Golding & Stephens, 2017) .According to (Burns, 2017) It is essential accurately diagnose Otitis media to reduce overtreatment and antibiotic resistance, and There are different types AOM, Suppurative effusion of the middle ear, other is Bullous myringitis AOM in which bullae form between the inner and middle layers of the TM and bulge outward, persistent when AOM that has not resolved when antibiotic therapy has been completed or AOM recurs within days of treatment and recurrent when Three separate bouts of AOM within a 6-month period or four within a 12-month period; often a positive family history of Otitis media and other ENT disease, to support this diagnosis Left tympanic membrane Erythematous and bulging with diminished light reflex is showed in the ear exam

Differential diagnosis

Diffuse Otitis Externa (OE), commonly called swimmer’s ear, is a diffuse inflammation of the external auditory canal (EAC) and can involve the auricle, or both. Inflammation is evidenced as simple infection with edema, discharge, and erythema; furuncles or small abscesses that form in hair follicles; or impetigo or infection of the superficial layers of the epidermis. OE results when the protective barriers in the EAC are damaged by mechanical or chemical mechanisms. OE.The most common causative organisms are Pseudomonas aeruginosa and Staphylococcus aureus (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). This diagnosis was ruled out based on no complaints of itching and symptoms of the disease.

Other differential diagnosis to take into consideration: The assessment conducted also rules out mastoiditis, cholesteatoma, otitis externa and otitis media with effusion.

Mastoiditis: It is an inflammatory of the mastoid in the temporal bone. The mastoid is a structure contiguous to the middle ear cleft and an extension of it. The clinical presentation is characterized by symptoms involving the middle ear such as fever, local pain, and conductive hearing loss. Typically, patients with this illness presented with fever, irritability, lethargy, swelling of the ear lobe, Redness and tenderness behind the ear, Drainage from the ear, Bulging and drooping of the ear (Burns et al, 2017). This is also not the case were presented, so it is discarded.

Miryngitis: These patients may have no symptoms attributable to the middle ear.On otoscopy there is erythema and injection of the tympanic membrane in the neutral position without other features of otitis media.

PLAN

No labs /Diagnostic test ordered

Pharmacological treatment:

Amoxicillin 500 mg 1 tab PO every 12 hours for 10 days (dosage (90mg/kg/day)

Acetaminophen 325 mg 1 cap PO every 4-6 hours PRN for fever or pain (dosage 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day)

Non-pharmacological measures:

Patient’s mother has been educated on increasing the fluids and to uses less clothing. Popsicles and iced drinks are helpful to recover the body fluids that are lost during fevers because of sweating. Sponging is a method that can be used to reduce the fever along with the Acetaminophen prescribed. Patient’s caregivers were recommended to not sponge the child without giving Acetaminophen first.

Education:

-Avoid Q tip use.

-Proper Nutrition/rest

-Proper use of antibiotics is important and misunderstanding of technique can lead to treatment failure. For this reason, placement of drops should be taught in the office. Xylitol, probiotics, herbal ear drops, and homeopathic interventions may be beneficial in reducing pain duration, antibiotic use, and bacterial resistance.

-Even though an ear infection is not transmissible, the causative biological agents (bacteria or virus) are often passed from person to person. It’s very important to take into account the following measures: vaccination against Pneumococcal injection your child with a pneumococcal conjugate vaccine to protect against several types of pneumococcal bacteria. This type of bacteria is the most common cause of ear infections.

-Practice routine hand washing and avoid sharing food and drinks, especially if your child is exposed to large groups of kids in day care or school settings.

-Avoid second-hand smoke. Recommendation against cigarette smoke exposure is one of the most important measure to practice preventing Otitis media.

Referral/Follow up: No referral needed at this moment. Monitoring 48 hours after therapy if experiencing worsening symptoms, if current treatment is not successful to treat the condition, or new symptoms/side effects develop.

References

Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., and Garzon, D. L. (2017). Pediatric Primary Care (6th ed.). St. Louis, MO: Elsevier.

Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary Care: Collaborative

Practice, (4th ed.) Elsevier ISBN: 978-0-323-35501-8 or eBook on Intel Education Study13-978-1

4963-3996-6. Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013 Mar;131(3):e964-99. [Erratum in Pediatrics. 2014 Feb;133(2):346

Mankowski NL, Raggio BS. Otoscope Exam. [Updated 2019 Dec 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK553163
.

Uhari M, Mantysaari K, Niemela M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis. 1996 Jun;22(6):1079-83.

Soap Note Deadlines and Guidelines

· Soap notes must be done in Proper APA Format

· You may not repeat the same Diagnosis more than once.

· Notes with more than one diagnosis must focus on one main diagnosis

· Main Diagnosis must include a rationale with in-text reference (Why you chose this diagnosis backed by evidence-based practice)

· All Diagnoses on note must include ICD 10 Codes

· Notes must have a Minimum 3 differential diagnoses

· Notes must have Minimum of 2 Scholarly References (Journals, Books, and Studies)

· All notes must be of 6 Pediatric only in this clinical rotation

Soap Note Grading Rubric

This sheet is to help you understand what is required, and what the margin remarks might be about on your comments of patients. Since most of your comments that you hand in are uniform, this represents what MUST be included in every write-up.

·
Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

·
Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written in this manner.

·
Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

· Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

· Pertinent positives and negatives must be documented for each relevant system.

· Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

·
Assessment (___10pts.): All diagnoses should be clearly listed and worded appropriately with ICD 10 codes. Rationale and Explanation must be evidence based and have 1-2 in text references to back up your reasoning for making your main diagnosis selection. 3 differential diagnosis must be noted, rationale not required but encouraged.

·
Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. Should not be generic information and should be tailored to your patient and their needs / specific diagnosis.

·
Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

Clarity of the Write-up(___5pts.): Is it literate, organized, and complete?

Guidelines for SOAP Notes

General Guidelines:

· Label each section of the SOAP note (each body part and system).

· Do
not use unnecessary words or complete sentences.

· Use Standard Abbreviations

· All Heading and Subheadings must be bolded and separate, no narrative ROS or Physical (Paragraph Form)

All Soap Notes must include:

· Full name of student

· Date of encounter

· Name of Preceptor and Clinical Instructor

· Title with Soap # and Main Diagnosis (Soap # 3 DX: Hypertension)

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Identifying/Demographic Information: The opening list of the note. It contains age, sex, race, etc.

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit.
The patient’s own words should be in “quotes”. . If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, surgical history and hospitalizations, age-appropriate immunization status, age appropriate screening control, Pediatric Developmental Milestones, Woman Health Menstrual History/ Obstetric History

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children).
Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education, Exercises , Diet, Sexual history, Abuse/Safety history.

Review of Systems (ROS). There are
14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

All Sections must be included in all soap notes

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Vital Signs: Blood Pressure, Pulse, Respiratory Rate, Temperature, Height, Weight and BMI (with percentile in case of pediatric patient) , If needed other Measurements: ( PED: Head/Abdominal Circumference ), (WH: Fundal Height(cm), Fetal Position , Fetal Heart Rate(bpm),Pain level ( scale 0-10)

Physical Exam: Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings.
Abnormal or unexpected findings should be described, Record observations for the following systems for each patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vital signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing.

Order/Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

There must be one main Diagnosis

Remember:
Your subjective and objective data should support your diagnoses and therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For the main diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

Must include a Minimum of 3 Differential diagnosis with ICD codes and provide a cited rationale for each differential diagnosis

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation. (in-text citation)

1. Prescribe: Medications/Vaccine/Devices etc, write out the medication/Vaccine prescription including dispensing information ( presentation , dose, route , frequency , length of treatment) and provide EBP to support ordering each prescription.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education/Teaching/ Instructions this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

6. References: Notes must have Minimum of 2 Scholarly References (Journals, Books, and Studies)

Academic Dishonesty and Plagiarism

Academic Misconduct Statement

Academic Misconduct includes: Cheating – The unauthorized use of books, notes, aids, electronic sources; or assistance from another person with respect to examinations, course assignments, field service reports, class recitations; or the unauthorized possession of examination papers or course materials, whether originally authorized or not. Plagiarism – The use and appropriation of another’s work without any indication of the source and the representation of such work as the student’s own. Any student who fails to give credit for ideas, expressions or materials taken from another source, including internet sources, is responsible for plagiarism.