Soap Note Pediatric Patient Case Study

SOAP NOTE: PEDIATRIC PATIENT CASE STUDY 1

SoapNote: Pediatric Patient Case Study

ChiefComplaints (CC): Vomiting, Nausea, and fatigue for 2 days. Noheadache or fever.

History ofPresent Illness (HPI): CJ is a 6-years-old girl brought by hermother to a pediatric clinic due to complaints of fatigue, nausea,and vomiting. The history of her present illness dates back to 3 daysago when she started vomiting and complaining of stomach pains. Itwas until a day ago when she started experiencing nausea. The vomitusshe discharged was liquid-like and was mixed with undigested food.Her mother noted that CJ`s stool had no blood or mucus. The child`svomiting was also irregular having vomited only once the previous dayand twice that morning.

On the other hand, CJ was interviewed by the pediatrician and gave aslightly different history about her condition. Having stated almostall the above, she added that she had vomited more than once theprevious day. She also said that the stool was slightly hard. Thepossible reasons for these discrepancies could be because the motherwas not with the child the whole time. It could also be because CJcould not have been well aware of her condition.

Drugs/medication:The patient showed no history of regular medication.

Allergies: Noallergies.

Past MedicalHistory (PMH): No history of surgeries.

Immunization:Updated.

Family History:CJ has 2 younger siblings with no medical problems.

Reviewof Systems

General: Thepatient did not open up to having any other issues.

Skin: Dry withabdominal rashes

Eyes: Clearvision

Nose, Ears, andThroat: The patient denies having any hearing issues, nasaldischarge, drainage, or throat congestion.

Neck: Slightpain, easiness in swallowing.

Respiration: Noshort of breathe, or coughing.

Gastro urinal: Nohematuria.

Neurological: Noconfusion or headache.

Cardiovascular:There was no chest discomfort, ankle edema, or murmur.

Musculoskeletal:No ambulating or loss or balance.

Objectivedata: CJ`s recorded heart rate was at 91 beats per minute at thetime of assessment and her body temperature stood at 97.6 F. CJ’sblood pressure was at 123/76, while the oxygen saturation stood at96% room temperature. For a six-year-old like CJ, her recorded weightwas at 43.5, while she stood at 40 feet tall. Also, her calculatedBody Mass Index stood at 19. Generally, CJ appeared to be well-fedand taken care of with no single sign of distress, neglect, orphysical abuse.

When her skin was examined, however, it was a bit rough and sectionsof it on the chins, forehead, and the abdomen had rashes. There wasalso a slight change in skin color, experiences turgor concerns, andirregular stomach irritation. The eyes are also teary and areabnormal. However, the neck area has no masses, and her respiratoryprocess appears normal. Regarding cardiovascular, there are murmurs.There is tenderness in her bladder, but with a steady gait, and nomood swings recorded (Dennehy, 2011). The patient in question, CJ,presented for study showed a series of psychosocial struggles. Forinstance, from the above physical assessment, there are indicationsof her withdrawal from nature and her social life.

PatientAssessment

Priority diagnosis: Regarding the diagnosis based on the casestudy, CJ’s main diagnosis is the Bacterial Gastroenteritis. Thismeans that it rules out the possibility of the other two diagnoses –Viral Gastroenteritis and Cyclic Vomiting Syndrome. According toGuandalini &amp Vaziri (2011), stomach infection, as is the casewith CJ, is characterized by feelings of nausea and having waterystools. Here, the primary diagnosis could be due to either foodpoisoning or gastroenteritis etiology.

DeferentialDiagnosis: Bacterial Gastroenteritis – this is a diagnosis,which refers to inflammation of the abdomen caused by Salmonellacolitis. The condition is characterized by continuous vomiting,irritation of the stomach, and feelings of discomfort. If thecondition is not urgently checked, it may end up to causing otherstomach illnesses.

ViralGastroenteritis – This diagnosis refers to a series of acuteirritability, more so on the patient`s inner walls and the stomachlining. Viral Gastroenteritis is characterized by continuousvomiting, feelings of nausea, and exuding watery stool (Bradley etal., 2012). It can also result in the body experiencing excessivewater loss, and in turn, results in the dehydration of the body.

Cyclic VomitingSyndrome – This diagnosis is regarded as of the major symptoms,which is patient’s recurrent vomiting. It is also characterized bythe pains in the abdominal area. Considering CJ’s condition, sheshowed instances of these pains from within the stomach lining,according to her mother.

Food poisoning –this is as a result of one engaging in foods and drinks laced byinfection, for example, staphylococcus. A victim of food poisoning ischaracterized by dry mouth, nausea, vomiting, and abdominal pain.Frequently, the staphylococcus infection is a bit implicated.

Plan:The treatment of Bacterial Gastroenteritis in children, for example,CJ, would be solved by making sure the patient is well-dehydrated.If, for instance, the ORT is not readily available, water should beused. CJ is expected to continue with the usual diet, while payingattention to using the recommended probiotics (Burns et al., 2013).In turn, it will make sure the diarrhea levels are minimized. Theantiemetic medications should be used to stop vomiting. Additionally,the patient will be required to visit the pediatrician clinic in thenext 10 days for further checkups.

Health/EducationPromotion and Disease Prevention: CJ’s mother wasknowledgeable, especially on the importance of her child’s hygiene.In their household, there is need to pay attention to surfaces thatneeds to be disinfected and cleaned. CJ has to be encouraged to avoiddeep pools and dirty surfaces. Additionally, parents are advised togo back to the clinic if there observe bloody or watery stools.

Reflectionnotes: The above Bacterial Gastroenteritis treatment isagreeable. My &quotaha&quot moment was when probiotics were usedfor the treatment of the diagnosis. What I would do differently isdisregard the use of antibiotics. In turn, I would embark on the useof medication, which is targeted at stopping vomiting and nausea. Ina similar patient evaluation, I would opt for a probable treatmentmeasure, which will not interfere with the patient`s diet. I wouldemphasize on oral hygiene of the patient.

References

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., &amp Blosser,C. G. (2013). Pediatric primary care (5th ed.). Philadelphia,PA: Elsevier. Chapter 30, “Cardiovascular Disorders” pp. 669–707

Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter,E. R., Harrison, C., Swanson, J. T. (2011). The management ofcommunity-acquired pneumonia in infants and children older than 3months of age: Clinical practice guidelines by the PediatricInfectious Diseases Society and the Infectious Diseases Society ofAmerica. Clinical Infectious Diseases, 53(7), e25–e76.Walden Library databases

Dennehy, P. H. (2011). Viral gastroenteritis in children. ThePediatric Infectious Disease Journal, 30(1): 63-64

Guandalini, S., &amp Vaziri, H. (2011). Diarrhea: Diagnostic andtherapeutic advances. New York, N.Y: Humana Press.