SOAP Note Evaluation Pediatric Case Study Paper
Patient Information:
Initials: NM Age: 6 years Gender: M Race: Caucasian
Subjective:
Chief complaint (CC):
The patient presents to the clinic with his mother who reports that “my child has been coughing for seven days.”
History of Presenting Illness (HPI):
The patient is a six-year-old Caucasian boy brought to the clinic by his mother for medical attention due to a cough that she says has been present for seven days. The cough is worse and more frequent at night, only occasionally during the day. The cough itself is not productive but the child has a runny nose which produces a yellow-green discharge at the back of the throat (post-nasal drip. The child says there is some drainage at the back of the throat that he swallows most of the time). The mother has noted some swelling around the eyes of her son and the boy has also been having mild fevers. He has complained of headache several times over the past seven days to which she has given him acetaminophen 250 mg orally PRN with good effect. The symptoms have been consistent in their presentation and he has only had some relief when he is given the over-the-counter (OTC) medication. He has nausea, not feeding well, but is passing urine with normal color and volume. His siblings have thus so far not fallen ill. SOAP Note Evaluation Pediatric Case Study Paper
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Current Medications (OTC):
- Children’s Tylenol (acetaminophen) 160 mg/ 5 ml, 10 ml TDS/ PRN for 7 days.
- Children’s Sudafed nasal decongestant (pseudoephedrine HCl) 15 mg/ 5 ml, 10 ml PO QID for 7 days.
Allergies:
The child has no known drug allergies. However, he has environmental allergies to pollen, dust, and cigarette smoke.
Past Medical History (PMH):
The boy was born normally by spontaneous vertex delivery at 37 months of gestation in good health. He had a satisfactory Apgar score of 9, 10, and 10 at birth and had no post-delivery complications. The mother’s pre-natal period had been uneventful. He has never been admitted to hospital since birth: he has only been treated for occasional colds, fever, and coughs.
Surgical History:
No surgical history.
Social or Home History:
He lives with his mother, father, and two other siblings. The older sibling is a brother aged nine years old and the younger sibling is a sister aged three years old. They keep no pets at the moment but the father smokes cigarettes. However, he usually smokes outside on the front porch. The father is a truck driver and can be on the road for a few days at a time before returning home. He came back about a week ago and has been home since. The mother is a registered nurse at the local hospital. The family is financially comfortable and can meet all their needs. Neither parent uses a mobile phone while driving, and always wear their seat belts. SOAP Note Evaluation Pediatric Case Study Paper
Family History:
Allergy history present on both sides of the family. The mother herself has environmental allergies to dust, smoke, and particles such as pollen. The grandmother on the father’s side had asthma. There is no additional history of chronic illness on either the maternal and paternal side.
Immunizations:
At six years of age, the boy has had all the required immunizations to date. He received the first dose of hepatitis B vaccine at birth. At one month old, he then received the second dose of Hep B. He received his initial dosages of the rotavirus, diphtheria, tetanus, pertussis (DTaP), Hemophilus influenzae type b (Hib), pneumococcal conjugate (PCV13), and inactivated poliovirus (IPV) vaccines when he was two months old. All of these vaccines were given in accordance to the Centers for Disease Control and Prevention’s recommended vaccination regimen (CDC, 2023). The child received the third dose of DTaP and the third dose of pneumococcal conjugate, or PCV13, at the age of six months. He received Hep A first dose at 12 months. He had received the third dose of the hepatitis B vaccine and IPV at the age of nine months. The boy received the third dosage of the Hib vaccine, the first doses of the measles, mumps, rubella (MMR) and varicella (VAR), and the second dose of the hepatitis A (Hep A) vaccine at the exact age of two years. He received the fourth doses of DTaP and PCV13 at 15 months. The annual dose of influenza, or IIV4 vaccine, was the other vaccination that he received at the age of 15 months. The infant was immunized against Hep B (third dosage), DTaP (fourth dose), and IPV at 18 months (third dose). He has also received the annual vaccination for influenza (IIV4), DTaP fifth dose, IPV fourth dose, Covid-19 three doses, MMR second dose, and VAR second dose; all between 18 months and 24 months. This child is up-to-date with immunization and has not missed any one of the vaccines. SOAP Note Evaluation Pediatric Case Study Paper
Review of Systems (ROS):
GENERAL: Through his mother, denies headaches, fatigue, chills, loss of weight, and fever.
HEENT: He claims to have headaches but disputes being photosensitive or having vision issues. He refutes any unnatural eye weeping. Additionally, he claims to have neither tinnitus nor ear discharge. He tests positive for nasal discharge but neutral for sneezing and polyps. When questioned about his larynx, he claims he does not have a sore throat or trouble swallowing.
SKIN: The patient and his mother deny the presence of rashes, eczema, and itchiness of the skin or other abnormal skin presentations.
CARDIOVASCULAR: The patient denies having chest pain, palpitations, or tightness. The mother denies any edema of the upper and lower limbs.
RESPIRATORY: The patient denies having difficulties with breathing, including wheezing but does report coughing.
GASTROINTESTINAL: The patient reports nausea but denies diarrhea or vomiting. He claims to have poor appetite and often feels like not eating. He checks negative for having abnormal or inconsistent bowel movements. The day before the clinic appointment was when the last bowel movement was reported.
GENITOURINARY: Painful urination and cloudy urine are not present. He disputes passing excessive or insufficient quantities of urine. The mother disputes the boy having nighttime enuresis.
NEUROLOGICAL: The patient disputes experiencing lightheadedness, fainting, losing consciousness, or tingling in all limbs. He claims that he is not experiencing any noticeable physical decline. Additionally, he disputes losing control of his bladder or bowels.
MUSCULOSKELETAL: The patient disputes any muscular or joint pains. As far as he can recall, he also says that he has never experienced back discomfort.
HEMATOLOGIC: According to the mother, there is no family history of clotting or blood conditions. SOAP Note Evaluation Pediatric Case Study Paper
LYMPHATICS: The patient is positive for cervical lymphadenopathy but denies previous splenectomy.
ENDOCRINOLOGIC: There are no signs of excessive hunger, excessive thirst, or excessive perspiration by the patient. He rejects having sensitivity to heat or cold, and his mother disputes any history of previous hormonal treatment.
Physical Examination
Vital Signs: BP 100/63 mmHg, HR 84 bpm; RR 20 pm; T 100.22 ⁰F (37.9 °C); Wt. 21.6 kg (31.3 lbs); Ht. 110.1 cm; BMI 17.8 kg/m2 (92%: healthy but borderline)
General: The boy is attentive, organized, well-groomed, talkative, and lively. He appears to be a healthy weight and height for his age.
HEENT: The head is atraumatic and normocephalic. Fontanelles have already closed. Peri-orbital edema or swelling noted bilaterally. No cerumen impaction or otorrhea. The tympanic membranes are both intact and the hearing is excellent. Bilaterally PERRLA, EOMI. There was significant rhinorrhea but no thrush or erythema of the pharynx.
Cardiovascular: S1 and S2 audible and clear, regular rate and rhythm (RRR). There are no audible murmurs or bruits.
Respiratory: The lung fields are clear bilaterally with no rales, rhonchi, or crepitations.
Musculoskeletal: There is good muscle tone and strength as well as normal reflexes in all four limbs.
Genitourinary (GU): There are no signs of infection, lumps, lesions, or discharge. Both of his testes are well descended into the scrotum and palpable with no cryptorchidism. Urine sample is unremarkable.
Gastrointestinal (GI): On inspection there is no discernible distension of the abdomen. Percussion reveals no abnormalities. Clear bowel sounds can be heard on auscultation in all four quadrants, with no tenderness or organ enlargement palpated. SOAP Note Evaluation Pediatric Case Study Paper
Developmental Theory
Piaget: The concept of cognitive development, which has four stages from birth to adolescence, was created by Jean Piaget. These include the sensorimotor stage (from birth to age two), the preoperational stage (from age two to age seven), the concrete operational stage (from age seven to age 11), and the official operational stage (from age 12 to age 19) (McLeod, 2022). This boy’s cognitive development is in the preoperational period. Although he is growing normally, he has not yet used cognitive functions as would typically be anticipated: he thinks before acting but cannot yet apply concrete logic.
Erikson: According to Erik Erikson’s theory of psychosocial development, this child is in the stage named ‘industry vs. inferiority’ that runs from five to 12 years of age (McLeod, 2023). He is learning to read, write, and do sums on his own. He is meeting all the competency standards required at this stage.
Expected development: The boy’s fine and gross muscle development is anticipated to continue in the same manner as it has progressed thus far. He has had all the necessary immunizations for his age and has never had any health issues since infancy. SOAP Note Evaluation Pediatric Case Study Paper
Assessment:
Differential Diagnoses
Rhinosinusitis
The signs of rhinosinusitis (RS) in children may differ from those in adults. Children are more likely to have a cough, halitosis, irritability, poor energy, eye swelling, and thick, yellow-green postnasal or nasal drip (Hammer & McPhee, 2018; Jameson et al., 2018; Maaks et al., 2019). RS refers to inflammation of the paranasal and nasal sinus mucosae. Subacute RS may last one to three months, persistent RS may last longer than three months, and acute RS may last up to one month. The length of symptom persistence is what is used to classify the disease itself.
A child is identified with acute bacterial rhinosinusitis (ABRS) based on a number of factors such as: persistent upper respiratory tract symptoms being present for more than 10 days, including cough or nasal discharge or both; or recurring manifestations after the first improvement: fever, deteriorating cough further escalating, or fresh purulent nasal discharge; serious onset of manifestations such as a high temperature or purulent nasal discharge spanning more than three successive days correlated with facial pain or headache (Hammer & McPhee, 2018; Jameson et al., 2018; Maaks et al., 2019). Streptococcus pneumonia, Haemophilus influenza, and Moraxella catarrhalis are common bacteria associated with ABRS (Jameson et al., 2018). In children, viral upper respiratory tract infections can advance to ABRS in some cases, while other cases progressing to chronic rhinosinusitis. According to Jameson et al. (2018), since viral rhinosinusitis and ABRS have the same clinical and radiological findings, it is challenging to tell them apart when they appear similarly. SOAP Note Evaluation Pediatric Case Study Paper
Pertinent positives: post-nasal drip, peri-orbital swelling, cough, fever, and mucosal inflammation as seen on X-ray.
Pertinent negatives: absent anatomical aberrations on rhinoscopy.
Meningitis
An infection of the delicate membranes that surround the brain and spinal cord is known as meningitis. Most frequently, a viral or bacterial illness that enters the cerebral spinal fluid is to blame. Meningitis can also be brought on by a parasite or fungi (Hammer & McPhee, 2018; Jameson et al., 2018). Fever, headache, stiff neck, sensitivity to light, drowsiness, and disorientation are symptoms of viral meningitis. On the other hand, symptoms of bacterial meningitis include high temperature, excruciating headache, stiff neck, sensitivity to light, drowsiness, and confusion. According to Jameson et al. (2018), there may also be a rash, nausea, vomiting, and sore tongue.
Pertinent positives: Fever, headache, stiff neck, sensitivity to light, drowsiness.
Pertinent negatives: Lack of photosensitivity and confusion.
Foreign body
Foreign bodies in the ear, sinus, and throat are a frequent issue seen in practice, particularly in emergency rooms. When their parents discover or assume foreign objects in their children’s ears, noses, or throats, children frequently go to emergency rooms (Jameson et al. 2018). Children who are in an exploratory developmental period frequently put things in their mouths, noses, and ears. Jameson et al. (2018) state that these children either do not exhibit any symptoms at all or exhibit atypical symptoms like crying, generalized pain, refusing to eat, and having blood-stained saliva. SOAP Note Evaluation Pediatric Case Study Paper
Plan of Care:
Diagnostic Tests:
- Complete blood count with differentials (leucocytosis found).
- C-reactive protein (found to be elevated).
- Erythrocyte sedimentation rate (found to be elevated).
- Anterior rhinoscopy (shows mucosal edema, obstructive polyps, and mucous crusting).
- Plain sinus X-ray (indicates mucosal thickening and sinus opacity).
- Throat swab for C/S of the purulent post-nasal drip (awaited) (Hammer & McPhee, 2018; Jameson et al., 2018).
Pharmacologic
- Amoxicillin-clavulanate 20 mg per kg of body weight per day every eight hours orally for seven days (Rosenthal & Burchum, 2018).
- Children’s Tylenol (acetaminophen) 160 mg/ 5 ml, 10 ml TDS/ PRN for 14 days (Rosenthal & Burchum, 2018).
- Children’s Sudafed nasal decongestant (pseudoephedrine HCl) 15 mg/ 5 ml, 10 ml by inhalation every six hours for 10-14 days (Rosenthal & Burchum, 2018). SOAP Note Evaluation Pediatric Case Study Paper
Non-pharmacologic Treatment
- Encourage plenty of rest.
- Drinking of plenty of fluids.
- Apply a warm compress on the nose and forehead as required.
- Warm, moist air inhalations (Mayo Clinic, 2021).
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Patient Education and Anticipatory Guidance
Medicines should be kept where the children cannot reach them. The mother should look out for medication side effects and signs and symptoms that may include a worsening of the condition. The child should be given sufficient fluids, fruits and vegetables in the diet (AAP, 2017; Richardson, 2020). The mother should make sure he gets all pending vaccines and that he remains physically active after getting well.
Follow Up
The mother is told that she can call the office at any time if she has a concern. The follow up is scheduled for one week from now. By then, the culture and sensitivity results will be available, even though the boy will already be on empirical antibiotic therapy. Anterior rhinoscopy will be repeated at the follow-up appointment as well as a plain sinus X-ray to evaluate the patient’s progress and response to treatment. SOAP Note Evaluation Pediatric Case Study Paper
References
American Academy of Pediatrics [AAP] (2017). Bright futures: guidelines for health supervision of infants, children, and adolescents, 4th ed. APA.
Battisti, A.S., Modi, P., & Pangia, J. (2022). Sinusitis. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK470383/#:~:text=Differential%20Diagnosis&text=Tension%20headaches%2C%20vascular%20headaches%2C%20foreign,mistaken%20for%20sinusitis%5B9%5D
Centers for Disease Control and Prevention [CDC] (2023). Child and adolescent immunization schedule. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.
Maaks, D.L.G., Starr, N.B., Brady, M.A., Gaylord, N.M., Driessnack, M., & Duderstadt, K.G. (2019). Burns’ pediatric primary care, 7th ed. Elsevier.
Mayo Clinic (2021). Acute sinusitis: Diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/acute-sinusitis/diagnosis-treatment/drc-20351677
McLeod, S. (2023). Erik Erikson’s stages of psychosocial development. Simply Psychology. https://www.simplypsychology.org/Erik-Erikson.html
McLeod, S. (March 8, 2023). Jean Piaget’s theory and stages of cognitive development. Simply Psychology. https://www.simplypsychology.org/piaget.html
Richardson, B. (2020). Pediatric primary care: Practice guidelines for nurses, 4th ed. Jones & Bartlett Learning.
Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.
PLEASE FIND ENCLOSED THE INSTRUCTIONS.
They are very sensitive regarding supporting pathophysiology of 1st differential diagnosis- medication dosage and duration is super important
Pathophysiologic support for primary DD
One of the sources should be :BURNS’ PEDIATRIC PRIMARY CARE
by Dawn Lee Garzon Maaks, Nancy Barber Starr, Margaret A. Brady SOAP Note Evaluation Pediatric Case Study Paper