NSG 5540 CASE STUDY: COMPREHENSIVE SOAP NOTE

Sample COMPREHENSIVE SOAP NOTE

COMPREHENSIVE SOAP NOTE

Identifying Data: Age, Gender, Occupation, and Marital Status

Initial: J.M Age: 8.5 Months Gender: Male Occupation: N/A Marital Status: N/A

 Source and Reliability: Mother to the Child who works as a nurse attendant.

  1. SUBJECTIVE:

 Chief complaint or appropriate health screening visit: The patient’s mother states, ‘I think my boy has an ear infection.’

HPI: 

JM is an eight-and-a-half-month-old baby boy who is healthy-looking and presented to the clinic by his mother with a likely infection on his right ear. The mother reports she noted something was amiss when she noticed the boy was pulling his right ear and exhibiting a low fever temperature of between 98 and 99 F in the last 5 days. The patient appears very irritable. Using the mnemonic OLD CHARTS.

The month reports the pain started five days ago, is located in the inner right ear, and the duration is five days or less than a week. According to the mother, she would describe the character of the pain as dull since the baby keeps pulling the right ear for periods lasting up to five minutes then stops for about an hour or so before pulling again. Wearing a monkey cap exacerbates the pain by alleviating factors like administering Tylenol liquid, which offers the baby some relief and even helps break the fever.

This can last for around 8- 10 hours. The pain radiates towards the inner ear as the pain sometimes cries if the liquid is not administered promptly. The pain appears to recur during the night and early morning or when wearing a monkey cap. Besides low-grade fever accompanying symptoms are irritability, sleeplessness, and fluid draining from the right ear that precipitates the visit to the clinic.

Medications, including OTC and Herbals Preparation

Tylenol liquid 5ml three times a day.

Past Medical History:

  1. Allergies – NKDA
  2. Childhood Illnesses –  To date, she has not suffered from any significant disease that would have led to hospitalization or surgery. The Child does not have any history of physical trauma.
  3. Adult Illnesses
    1. Injuries N/A
    1. SurgeriesN/A
    1. Hospitalizations N/A
    1. Obstetric/GynecologicN/A
    1. PsychiatricN/A
  4. Health Maintenance
    1. Immunization status – DPT, MMR, Influenza, Hepatitis, Polio, and Pneumovax mother has proven (immunization schedule card/ chart) that the boy has received all the immunizations recommended for his age
    1. Dental Exams (frequency and treatment) N/A
    1. Last eye exam (including results) was conducted 2 months ago; no vision problems detected since the baby could  look at and follow the object or toy displayed
    1. SBE/Pap/GYN (include results) N/A
    1. Testicular/rectal exam (include results) was conducted 5 months ago, and the testicles were determined to have descended to the scrum by then.

Family History: 

27 Yo mother has hypertension, 32 yo father has no known health issues, 4 yo sister have had otitis media that cured by the age of 3 years. Grandfather 68 yo with T2DM, Grandmother 58 living with HTN. 

Personal and Social History:

  1. Educational level N/A
  2. Personal interests N/A
  3. Lifestyle – exercise and diet N/A
  4. Older Adults – ADLs and ADLs N/A

Boy lives with father, mother, and sister in the fourth-floor apartment, mother reports having a good support system, mother denies neither parent smokes. She also indicates that her grandfather smokes and is an alcoholic but lives on the ground floor with is the spouse of 32 years.

Review of Systems: Pertinent positives and negatives in the differential diagnosis

  • OBJECTIVE:
  • Pulse oral 109
  • Respirations 30
  • Height 31 inches
  • Weight 30 lbs
  • BMI includes normal, overweight, obese, morbidly obese 17.9kg/m

ROS

General: Irritable and cries a lot,  has low-grade temp; denies  unusual weight gain or  loss, night sweats, fatigue, and chills

HEENT: Negative for head trauma, no eye discharge or vision problem

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COMPREHENSIVE SOAP NOTE
COMPREHENSIVE SOAP NOTE

Tugs and pulls at the right  ear, teething ;

Negative for hearing no, runny nose, mouth sores, and sore throat

RESP: Negative for  cough, sputum,  breath shortness or wheezing

CV: Negative for  cyanosis, swelling,  skin redness

G.I.: Negative for  constipation, abdominal pain, nausea, vomiting and diarrhea

GU: on  diapers at bedtime; Negative for urinating issues

MS: negative for recent injuries  and falls

SKIN: No rash, lesion, or chnges in color

 NEURO: Negative for  difficulty speaking and loss of consciousness

 PSYCH: positive for   difficulty sleeping, negative  behavioral changes, denies any  concerns for growth/development, and reports child is not hyperactive .

Physical Examination – specific systems as appropriate

GENERAL: Sitting on mother’s lap,

Appears to be irritable and exhibits a lot of crying .

 Patient tugging pulling and pulling his right ear

HEAD: Normocephalic, closed  fontanels , suture lines intact,  has evenly distributed hair

 EYES: PERRLA, white  sclera, pink conjunctiva , extra ocular movements intact; no bleeding  or pus noted

EARS: External appearance normal-lesions absent  erthymic , no  swelling noted. on otoscopic exam tympanic membranes and inner ear are red, have clooected  fluid behind the tympanic membrane. Hearing is intact.

NOSE: Nares patent bilaterally, septum midline,  mucosa normal andpink , no polyps or  discharge  noted

NECK: Neck is balanced, flexible, full ROM, non-tender unusual masses absent

 THROAT/MOUTH: Oral mucosa moist and pink; teething w/ two teeth noted; pharynx have no  redness, pus , or lesions.

LUNGS: Even and unlabored, on auscultation bilaterally clear and percussion without  dimished breath sounds rales,wheexing or  rhonchi,

 CV:, normal sinus rhythm with S1, S2 normal;  RRR, murmur, absent  clicks, rubs, or gallop

G.I.: Normal bowel sounds in all four quadrants. Abdomen is Soft, non-distended, non-tender; no guarding, rebound, or masses are present

 GU: No distended bladder. Both testes palpated. Redness or diaper rash absent.

SKIN: Warm, parched, unharmed, capillary refill < 2sec.;

 rash, lesion, pallor or cyanosis are all absent

MS: Full range of motion in all four extremities, general  normal function

  • ASSESSMENT

Differential diagnoses including ICD – 10 and Rationale:

  1. H 66.90 Otitis Media Confirmed unspecified – Using a pneumatic otoscope, the provider noted fluid buildup behind the eardrum. Sundavla et al. (2019) that otitis media manifests as ear pain,  fluid draining from one or both ears, tugging or pulling at one or both ears and a fever in infants. All these symptoms were present, leading to a confirming the otitis media diagnosis.
  2. Otitis Media With Effusion (OME) H65. 199 (Refuted)- diagnosed by non-infected fluid in the middle ear and common among pediatric patients (Pandey et al., 2018). This diagnosis was refuted as it occurs in the middle ear.
  3. Tympanic Membrane (T.M.) perforation H72.829 (Refuted)Characterized by an erupted (tympanic membrane ) or a tear or hole in the thin tissue separating your eardrum from your ear canal known as the tympanic membrane (Dolhi et al., 2021). This diagnosis is refuted as no rapture was observed.
  4. Cholesteatoma H71.01 (Refuted)characterized by the benign collections of keratinized squamous epithelium within the middle ear. It can be congenital or acquired. Congenital cholesteatoma is characterized by obstructions to the eustachian tube and leads to the accumulations of middle ear fluid and conductive hearing loss (Kennedy et al., 2021). The majority of these lesions are unilateral. Primary acquired cholesteatoma occurs as a result of tympanic membrane retraction. The diagnosis is refuted because no epithelium was observed.

4. PLAN

The first-line therapy is administering amoxicillin-clavulanate .125mg/5mL  oral suspension every eight hours (Sakulchit et al., 2017). Non-pharmacological interventions include educating caregivers on appropriate medication use, keeping the ear canal clean and room, and rest in acute pain and febrile phases.

There should be monitoring and follow-up in the next three days. Referral to an ENT specialist if the patients symptoms do not improve.

References

Dolhi N, Weimer AD. Tympanic Membrane Perforations. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557887/

Kennedy KL, Singh AK. Middle Ear Cholesteatoma. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448108/

Pandey, R., Zhang, C., Kang, J. W., Desai, P. M., Dasari, R. R., Barman, I., & Valdez, T. A. (2018). Differential diagnosis of otitis media with effusion using label-free Raman spectroscopy: A pilot study. Journal of biophotonics11(6), e201700259. https://doi.org/10.1002/jbio.201700259

Sakulchit, T., & Goldman, R. D. (2017). Antibiotic therapy for children with acute otitis media. Canadian Family Physician63(9), 685-687.

Sundvall, P. D., Papachristodoulou, C. E., & Nordeman, L. (2019). Diagnostic methods for acute otitis media in 1 to 12 year old children: a cross sectional study in primary health careBMC family practice20(1), 1-8.

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