NURS 6541 SOAP Note: HEENT

NURS 6541 SOAP Note: HEENT

NURS 6541 SOAP Note: HEENT

SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes.

 

Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Patient Initials:TM_ Age:        11        Gender:      Male

SUBJECTIVE DATA:

Chief Complaint (CC): Persistent cough

History of Present Illness (HPI): TM is 11-year-old African American male who presents today with a dry cough x 2 week. The cough is dry, slow and persistent. He reported that it started with a sore throat for 2 days, followed by a dry cough and chest congestion. 1–1e denied having fever or chest pain when coughs, but reported associated symptoms of dyspnea, malaise and occasional headaches, due to which he took a break from playing his usual soccer at school. He has not taken any medication. He also stated that he has had a poor appetite since then, even though his throat is no longer sore. He denied nausea/vomiting. He rated the severity of his symptom discomfort at 2/10.

Medications:

Robitussin 5ml every 12 hours for cough

Albuterol 1–IFA 90mcg/puff, 2 puffs every 4-6hr pm

Allergies: no known drug/food/ environmental allergies

Past Medical History (PMH): Asthma Onset:2014 with no hospitalizations.

NURS 6541 SOAP Note: HEENT

Past Surgical History (PSH): No surgeries

Sexual/Reproductive History: not applicable; not sexually active

Personal/Social History: He lives with both his parents and one younger sister. He is in 6th grade. He reports that he likes going to school and is doing well in school. Father is a fire fighter; Mother is a store manager. No drugs/alcohol/tobacco use in the home. He eats regular food and sleeps well except for when he is congested.

Immunization History: all vaccines up to date

ROS: Positive for dry cough, chest congestion, malaise and change in appetite, dyspnea, headache. Wo asthma with albuterol use. Negative for sputum, fever, chills, sore throat, weight loss, palpitations, nausea/vomiting, syncope,

OBJECTIVE DATA:

Physical Exam:

Vitals: T 98.6 orally, BP 100/60, pulse 88, RR 18, room air sat 99%, Ht 54inches, Wt 70.5 lbs., BMI 17.0.

General: Well nourished, healthy looking young man, no acute distress

HEENT: Head normocephalic, dark thick hair evenly distributed, PERRLA, sclera white, conjunctiva pink. Ears: clean canals bilaterally, throat no redness, pharynx intact, no drainage, no loose tooth

Neck: Supple, no masses, no palpable lymph node

Lungs: positive for fine rales, no consolidation, no wheezing or stridor, no tachypnea, no use of accessory muscles, no pleuritic chest symptoms. : fine rales with no consolidation,

Cardiovascular/Peripheral Vascular: RRR, no murmurs or gallops, peripheral pulses palpable, no edema noted

Gastrointestinal: Abdomen soft, nontender, nondistended. positive bowel sounds all 4 quadrants, no hepatosplenomegaly

Musculoskeletal: full range of motion all extremities

Skin: no rashes, skin warm to touch,

Diagnostic test results

WBC Count- normal

Assessment

NURS 6541 SOAP Note: HEENT

Priority diagnosis

Mycoplasma pneumonia — most common cause of lower respiratory tract infection in children older than fives through the young adult years (Burns et al., 2017). Symptom is slow at onset with dry cough malaise, head ache and sometimes fever. The child does not usually appear ill, but on lung auscultation, rales and rhonchi are frequently present; and CBC is usually normal (Dains et al., 2016). This is consistent with TM’s symptoms.

Bronchiolitis- occurs mostly in infants less than 2yrs old, and it is associated with fever, rhinorrhea and cough followed by wheezing and tachypnea. Cough increases as inflammation increases (Dains et al., 2016).

Bacterial pneumonia- usually associated with dyspnea, pleuritic chest pain, cough with greenish or rusty-colored sputum, fever and chills and inspiratory crackles on auscultation (Dains et al., 2016).

Plan

Medications discontinued

Robitussin 5ml every 12 hours is a cough suppressant and will be discontinued. Cough suppressants are not indicated since cough reflex and sputum expectoration enhance the removal of thick secretions (Buttaro et al., 2017).

Medications started

TM will be placed on:

Azithromycin 250mg tabs po daily for 5days.The long half-life of azithromycin allows for a shorter duration of therapy, which is usually 5 days (Buttaro et al., 2017).

Acetaminophen Suspension (160mg/5ml) q4-6hrs as needed for headaches; do not give more than 5 times a day.

Alternative therapies

Rest periods for malaise

Fluid hydration to keep mucous membranes and secretions moist and help bring up phlegm

Increased humidification with a cold mist vaporizer to provide moisture especially in dry climate (Burns et al., 2017).

Health Promotion strategies

Practitioners should educate patients and family on the avoidance of smoke and contact with people who have respiratory infections especially at home or in school, since it decreases the risk of pneumonia (Buttaro et al., 2017). Patient should be counseled at each visit on injury prevention and safety such as automobile and campus safety, and mental health such as stress, substance use and abuse, and eating disorders (Buttaro et al., 2017). Daily exercise, eating healthy foods high in vitamins, nutrients, and fiber should be encouraged (Buttaro et al., 2017).

Disease Prevention strategies

Practitioners in all settings should also screen and discuss the importance of immunization and risk factors to their patients at each visit. Patients at risk for pneumonia should receive the pneumonia vaccine and should also be encouraged to receive the flu shot (Buttaro et al., 2017). TM is up to date with all required vaccines. Patients should be educated on the potential side effects of each vaccines and should also be encouraged to keep a record of their vaccination history (Buttaro et al., 2017). A team approach to staff involvement also helps to enhance vaccination rate (Arcangelo & Peterson, 2013). Routine comprehensive adolescent visit at age 1 lyears is recommended to lay the ground work for future annual visits. In addition, yearly evaluation for sport physical should be completed for adolescents involved in sports, including orthopedic screening (Buttaro et al., 2017).

Diagnostic tests ordered

Chest x-ray in two weeks after antibiotic therapy

CBC in two weeks after antibiotic therapy

Referrals or consultation

if the pneumonia recurs or persists for longer than one month, TM will need further pulmonary evaluation, and a possible referral to a specialist or inpatient admission (Burns et al., 2017).

Follow-up: in office in 3 weeks to review lab and x-ray results or with any concerns

Education

Take azithromycin with food to prevent upset stomach (Arcangelo, 2013).

Symptoms can last for up to 6-8 weeks (Burns et al., 2017).

NURS 6541 SOAP Note: HEENT

Reflection

I learned that when M. pneumonia is suspected if cold agglutinins is present in the peripheral blood sample and is confirmed by mycoplasma IgM or PCR testing (Burns et al., 2017); and that a titer of 1:32 or higher supports the diagnosis (Dains et al., 2016). I did not know that chest x-ray is needed for the diagnosis of M. pneumonia. As reported by Buttaro et al. (2017), chest x-ray is recommended for all patients diagnosed with pneumonia, to both establish the diagnosis and rule out complications. However, a negative chest x-ray film does not exclude the diagnosis of pneumonia. I also learned that mycoplasma pneumoniae is one of the atypical and nonbacterial organism responsible for pneumonia because they lack cell walls and cannot be stained and visualized by conventional methods (Buttaro et al., 2017).

References

Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeuticsfor advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins. Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.).

(2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Buttaro, T. M., Trybulski, J., Polgar-Bailey, P. , Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).

Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.

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