Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Otitis media soap note example

08/10/2021 Client: muhammad11 Deadline: 2 Day

SOAP NOTE

Pediatric SOAP Note

Name: P. L

Date: 03/09/2018

Sex: Male

Age/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba

SUBJECTIVE

Historian: Mother and patient

Present Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”

Child Profile:

Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car.

HPI:

Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.

Med

Medications:

He is not currently taking any medications. Has taken Excedrin Extra Strength 1 tab orally by mouth as needed for headache in the past.

PMHX:

Allergies: NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up to date

Family History

Mother and father alive. Mother has history of GERD and father suffers from HTN. Paternal grandparents are deceased. Both of old age. Maternal grandfather and maternal grandmother are alive, and they only suffer from GERD and OA.

Social History

Patient is only child and lives with his parents. He is currently on high school. He is enrolled in a dual program where he is taking college classes in advance. He spends most of his time studying. He has applied to various universities and expects to obtain full scholarship. Mother denies guns at home or exposure to second hand smoking. Patient does not work because his school requires him to spend a great amount of time to it. Both parents are very supportive of patient. Patient denies being sexually active and denies having a girlfriend. He has a group of close friends.

ROS

General

Denies fever, weight loss or generalized weakness

Cardiovascular

Denies chest discomfort, palpitations, or chest pressure

Skin

Denies open wounds, rash, or hives

Respiratory

Denies for hemoptysis, tachypnea, dyspnea or cough

Eyes

Denies blurred vision, diplopia, and sense of curtain falling or intolerance of light. Positive for reading glasses.

Gastrointestinal

Denies nausea, vomiting, lack of appetite or changes in bowel habits

Ears

Denies ear pain, tinnitus, or discharge

Genitourinary/Gynecological

Denies changes in urine color, dysuria, or hematuria

Nose/Mouth/Throat

Denies mouth sores, epistaxis, nasal congestion, or difficulty swallowing

Musculoskeletal

Denies joint swelling, stiffness, or pain

Breast

Not examined

Neurological

Report headaches x 3 weeks. Negative for paralysis, tremors, seizures, speech difficulty or confusion

Heme/Lymph/Endo

Denies fatigue, anemia, cold/heat intolerance or enlarged lymph nodes

Psychiatric

Denies problems falling asleep or staying asleep, depression or suicidal ideations. Positive for high levels of stress and some anxiety

Weight 164 lbs

Temp 98.7

BP 122/63

Height 5’7”

Pulse 72

Resp: 18

General Appearance and parent‐child interaction:

Cooperative and calm patient accompanied by his mother. Both with clear and appropriate speech and language

Skin

Skin is intact. Good turgor. Capillary refill 2 seconds

HEENT

Head: Normocephalic, atraumatic. Eyes: symmetric. Normal eye lashes and lids, Clear conjunctiva. Visual fields full to confrontation. No ptosis. Pupils PERRLA. Ears: No trauma or drainage. Nontender tragus. Mouth: Intact gag reflex. Nose: Patent nares with midline septum. Neck: supple with no JVD and full ROM.

Cardiovascular

Normal heart rate and sounds. Pedal pulses 2+ bil. No cyanosis, clubbing or edema of the lower extremities

Respiratory

Lung fields clear to auscultation. Respiratory rate within normal parameter. Symmetric chest wall expansion. No use of accessory muscles observed.

Gastrointestinal

Abdomen is flat with normoactive bowel sounds in all quadrants. Exam negative for tenderness or guarding

Breast

Not examined during this visit

Genitourinary

No bladder distention or CVA tenderness

Musculoskeletal

Patient with full ROM. Normal spinal curvature and good head control. No joint deformities or inflammation seen.

Neurological

Extremities movable 5/5 strength. Intact coordination with finger to nose test. Intact sensation to light and deep touch. Reflexes 2 + throughout. Romberg test negative.

Psychiatric

Patient with adequate engagement in conversation, normal mood, no indications of depression at this time

In-house Lab Tests – document tests (results or pending)

MRI of the brain and cervical spine: Exam to be completed in an outpatient imaging

center as soon as possible

Diagnosis

Primary Diagnosis:

· Tension headache (G44.209): This diagnosis was selected based on physical examination and history of recent exposure to higher levels of stress. Pending MRI results to rule out other causes if any.

· Plan including education

· MRI scheduled for next day.

· Start Midrin 325 mg take 1 cap every 4 hours as needed for severe headache. Do not exceed 8 capsules per day.

· Motrin 800 mg 1 tablet every 8 hours as needed for pain

· Follow up in the office for tests results

Education

· Patient and mother educated about tension headaches and that they could be related to high stress levels. However, further testing was ordered to rule out other possible causes. Patient verbalized understanding and agreed to additional test to rule out more serious causes

Educated to keep a log with frequency of headaches

Instructed to take medications as prescribed and do not exceed recommended dosage.

Educated about the importance of a life –school balance, participate in physical activities, getting sufficient sleep and proper nutrition

Use relaxation and deep breathing techniques and take frequent brakes while using computer or other electronic devices (Donaldson, 2016)

Differential diagnosis -

1. Tension headache (G44.209): Tension headaches are

often described as dull pain on the back of the head or in

forehead. They are also called stress headaches and they

are often the result to high level of stress (Donaldson,

2016).

2. Brain tumor (C71.9): While many cases are

asymptomatic, a new onset of headache can warrant

further testing to rule out this diagnosis. According to

Prosad Paul, Perrow & Webster (2014), patients with

brain tumors can have persistent headaches, problems

with coordination, dizziness, fatigue or weakness. This

patient does not present other symptoms; however, this

differential diagnosis is a must no miss and therefore is

included for this patient.

3. Herniated cervical disk (M50.10): Although not very

common, serious cervical pathologies such as herniated

disk can cause headaches (Donaldson, 2016).

References:

Donaldson, S. (2016). Tension Headaches: Psychological Factors. Biofeedback,

44(1), 15-18. doi:10.5298/1081-5937-44.1.06

Prosad Paul, S., Perrow, R., & Webster, M. A. (2014). Brain tumours in children:

reducing time to diagnosis. Emergency Nurse, 22(1), 32-36.

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Assignments Hut
Financial Hub
Maths Master
Essay & Assignment Help
Homework Tutor
Calculation Master
Writer Writer Name Offer Chat
Assignments Hut

ONLINE

Assignments Hut

Hello, I an ranked top 10 freelancers in academic and contents writing. I can write and updated your personal statement with great quality and free of plagiarism

$42 Chat With Writer
Financial Hub

ONLINE

Financial Hub

Hello, I an ranked top 10 freelancers in academic and contents writing. I can write and updated your personal statement with great quality and free of plagiarism

$27 Chat With Writer
Maths Master

ONLINE

Maths Master

I have read and understood all your initial requirements, and I am very professional in this task.

$25 Chat With Writer
Essay & Assignment Help

ONLINE

Essay & Assignment Help

I am known as Unrivaled Quality, Written to Standard, providing Plagiarism-free woork, and Always on Time

$49 Chat With Writer
Homework Tutor

ONLINE

Homework Tutor

I am known as Unrivaled Quality, Written to Standard, providing Plagiarism-free woork, and Always on Time

$43 Chat With Writer
Calculation Master

ONLINE

Calculation Master

I have read your project details. I can do this within your deadline.

$21 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Life on the goldfields - Graphics - How much electricity does a waterbed heater use - Belkin usb peripheral switch windows 7 driver - Ati active learning template nursing skill - Qut academic calendar 2021 - The inn of lost time questions - Aat fundamental ethical principles - Financial statement analysis involves all of the following except - Substantive assessment methods definition - Wordly wise 3000 lesson 8 answers - PRJ656 Project Management Integration Framework - Healthcare quality book 3rd edition pdf - Distance from earth to mercury in scientific notation - Business finance - The cell address c5 indicates that the cell ________ - Liberty university ezproxy - Creating Value - Ascl3 ionic or covalent - RESEARCH PAPER - Research Paper - 17995 constitution circle hagerstown md - Fast sybr green master mix - The decision to outsource opens the firm up to certain risks, among them _________ and ________. - The affluent society galbraith pdf - Alice in wonderland theme - When did william golding die - Fallacy of catastrophic expectations - Dispositional biological and evolutionary theory newspaper article - Christmas tree circuit game - Girl by jamaica kincaid prezi analysis - What was the cause of the cuban missile crisis - Journal - Carlos plans to build a grain bin - Alternative math short film tone - Lsd test statistics - 90 euros to us dollars - Competent leader award application - Introduction to programming using visual basic 2012 - Bortons model of reflection - Cost estimation methods in management accounting - Urban assembly maker academy graduation rate - Pwdump for windows 10 - Animal farm pictures of characters - Bricklaying method statement free download - Value proposition canvas strategyzer pdf - Canton and hall daytripper watch review - Ammonium nitrate flame test color - Color Mixer - Finding gold in costa rican cloud forest - Example of continuity and change - Assessment strategies for lln - Movies strathpine greater union - A bookkeeper has debited an asset account for 3500 - 23 things they don t tell you about capitalism sparknotes - Power pressure cooker xl - A computer network consists of six computers - John brown and armed resistance - Penetration testing - Www aat org uk - Travis perkins water container - Devry plagiarism policy - Ausbil additional investment form - Bcit project management essentials - Should phones be banned in school persuasive - Dred scott political cartoon - Tax Form - Shorthand symbol for because - Managerial Economics: Assignment Summaries of below mentioned chapters from textbooks - Www thepaperbank co uk - Bacon's rebellion worksheet 3 1 answers - Contract bridge scoring chart - Paul von lettow vorbeck hitler - A rose for emily analysis essay - Home care care plan template - Limiting reagent lab vinegar and baking soda - Hampshire street lighting faults - Critique Research Assignment. Research of nursing - I need 1200 words 12 answers the Questions - Home nations discourage foreign direct investment outflows because it - For a bcc iron carbon alloy that contains - Restorative justice 4 schools - Doing ethics moral reasoning and contemporary issues 4th edition pdf - Dissertation Literature Review - Adrian fini net worth - 1.2 l to ml - Discussion 2 - What is sei strategies - Part time citizen legislature - Goodstart early learning webmail - Who is trevor noah's father - Harvard 3 minute step test - Fear in year of wonders - Betty parris personality traits - Burton smackdown toe binding straps - Origins reflection powerpoint - Econmovies episode 6 worksheet answers - Cash converters mt roskill - Developing ideas - Doosan 1600 compressor fault codes