Well child visit soap note example

Pediatric SOAP Note

Name (Initials only): T. A.

Date: 05/19/18

Sex: Male

Age: 26 months old DOB: October 2015

SUBJECTIVE: T. A. is a 26-month-old Caucasian male child accompanied to the office with his mother. His mother states she is bringing T. A. in for a tummy ache. She states the onset of the pain is two days ago. Location is in his abdomen. Duration is constant. Characteristic is unknown. Aggravating factors is if his mother touches him or picks him up. Relieving and treatment factors are nothing. T. A. ‘s mother states he isn’t himself lately, he has been listless, whining, maintaining poor eye contact and expression, and refusing to eat.

Historian: T. A. ‘s mother

Present Concerns/CC: Tummy ache

Reason given by the patient for seeking medical care “in quotes”

Child Profile: (Sexual History, If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)

T.A. is a 26-month-old male Caucasian child. He has a history of Down Syndrome and post atrial septal defect, repair with transient CHF as an infant. He does not attend daycare and his neighbors or mother’s boyfriend babysits him He has global development delay.

HPI:

T. A. is a 26-month-old male child with a history of Down Syndrome and a post-atrial septal defect that was repaired as an infant. He has no known allergies and does not take any prescription medication, OTC medications, or herbal medications. Mother states patient is clumsy and is always falling over things.

Medications: N/A

PMH: Down Syndrome, Global developmental delay, atrial-septal defect

Allergies: NA

Medication Intolerances: None

Illnesses/Major traumas: Down Syndrome, Global developmental delay, atrial-septal defect

Hospitalizations/Surgeries: Post-surgical repair for atrial-septal defect

Immunizations: Pt has received his immunizations except for the last ones.

Family History (Please identify all immediate family)

Father’s history is unknown. Mother has a history of anemia and his sister has asthma. No information on grandparents’ health.

Social History:

T. A. lives with his mother and two siblings who are 6 months old and 5 years old. His real father is not a part of his life and has never been with the family. His mother’s boyfriend, who is also the father of his 6-month-old sibling, sometimes stay over to babysit but he does not like to. T. A.’s mother is unable to afford daycare, so the neighbors help out to care for T.A. and his other siblings when she has to go to work. His mother is a cashier at a retail shop and her highest education level is the high school level.

ROS

General

Denies any sudden weight changes; fever, chills, and night sweats. The patient’s mother reports he has been very fussy, irritable

Cardiovascular

Mother reports a history of a hole in the heart (ASD) with transient CHF which has been resolved with surgery when he was an infant.

Skin

Denies rash, moles, or color changes in skin lesions.

Respiratory

Mother reports increased respiration with shallow

breathing.Denies cough, wheezing, hemoptysis, and history of pneumonia or TB.

Eyes

Denies problems with eye sight, discharge, redness, or discomfort to eyes.

Gastrointestinal

Mother states he has been complaining of tummy ache and that patient has not pooped in a while. The patient’s mother reports how he has been rubbing his abdomen as if it hurt him for the past two days and after a reported fall from the bed. Mother reports decreased appetite, bruise in the abdominal area, and one episode of vomiting last night.

Ears

Denies effusion, drainage, or redness

Genitourinary/Gynecological

Mother states patient is urinating less, and that urine smells strong and has a dark color.

Nose/Mouth/Throat

Denies drainage, septal deviation, or white patches.

Musculoskeletal

Denies deformities, stiffness, or joint pain.

Breast

Denies lumps or mass

Neurological

Denies seizures, numbness or tingling, paresthesia

Heme/Lymph/Endo

Denies heat or cold intolerance, no lymphadenopathy, no history of blood transfusion.

Psychiatric

Mother states T. A. I s not his happy usual self. He has been whining and refuses to eat. He is also listless.

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight 22 lbs. # (higher than 25th percentile %)

Temp 97.9 ° F

BP: 68/40 mmHg

Height 2’ 4” # (lower than 5th %)

Pulse 160 x’

Resp: 50 x’

General Appearance and parent‐child interaction

Patient is listless and appears ill.

Skin

Appropriate for race. Pale, cool, and clammy skin which is slightly mottled. Thoracotomy scar consistent with history of AV septal repair. Diffuse diaper rash. Faint circumferential macular discolorations at wrists consistent with aging ligature marks. 10 cm oval abdominal bruise.

HEENT

Head - No signs of head trauma. Down syndrome facies with flat face Eyes: Up slanting eyes, pupils equal round, and reactive to light bilaterally. Conjunctivae pink. Ears: Normal appearing external structures; no deformities or edema. No discharge noted. Tympanic membranes intact. No hemotympanum. No signs of otitis media. No discharge or polyps. Nose: Nasal mucosa pink; normal turbinates with clear drainage. Throat: No hoarseness, oropharynx not injected, clear mucosa, tonsils without exudate. Tongue normal color symmetrical no swelling or ulcerations. Normal gag reflex. Dental caries noted. Normal odor for breath. No visible scars, deformities, or other lesions. Trachea is midline and freely movable.

Cardiovascular

PMI non-displaced. S1, S2 regular rate and rhythm. Early systolic murmurs noted.

Respiratory

Non-labored movement of chest wall. Thoracotomy scar consistent with history of AV septal repair. Thorax atraumatic per gross inspection. Non-tender to chest wall, clavicle. The anterior lung fields are resonant. The left anterior chest (heart) and right lower chest (liver) are dull to percussion. The rest of the lung fields are resonant, and not hyper- resonant. Regular even unlabored, good expansion, no tachypnea or dyspnea. Symmetrical, no rhonchi, wheezing, or rales. Clear to auscultation.

Gastrointestinal

Ecchymosis overlying the epigastrium measuring 10 cm in longest diameter and oval in shape. Abdomen distended. 2 cm umbilical hernia. Abdomen distended, firm. Diffuse tenderness to palpation with associated guarding and rebound. Reducible umbilical hernia. No tympany or shifting dullness. Mild distention noted to abdomen.

Breast

Normal breast exam. The breasts and nipples are non-tender. There are no masses, lumps, tenderness, deformities, ulcerations, or discharge.

Genitourinary

Atraumatic, diffuse diaper rash, normal circumcised male, and testes descended, non-tender, no evidence of inguinal herniation.

Musculoskeletal

No overt limb deformities or bony crepitus. Moves all extremities spontaneously but weakly; no evident focal deficits. Faint circumferential macular discolorations at wrists consistent with aging ligature marks. No localized musculoskeletal pain to palpation of extremities. Normal bulk. No rigidity. Signs of trauma noted to abdomen with bruises. Normal range of motion of upper and lower extremities and joint. Spine straight gait normal. Spine is non-tender to vertebral palpation. No overt back deformities. Spine is non-tender to percussion. Normal and full range of motion. Normal 1.0 to 1.4 ratio of ankle to brachial B. (Abnormal ABI is less than 0.9 and is an indication of peripheral artery disease (PAD).

Neurological

No involuntary movements noted. Normal and full range of motion. Monofilament test is normal sensory test. Neurological Mental status for child’s development is verbal. Pt has global developmental delay. No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains.

Psychiatric

Patient has become withdrawn and is not his usual happy self per mother’s report.

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

Results – Abnormal CBC with differential which shows a 19,000 mm3 WBC, High Sodium (150), Potassium 6.0, Low Calcium – 7.0, Low Chloride 90, Carbon dioxide 12, High Urea Nitrogen 45, Creatinine 2.0, Albumin is low 2.5, Bilirubin low (0.5), Protein low 4.5, Alkaline is low (25), AST and ALT: WNL. Lipase is high (60). Lactic acid, serum is > 4. Prothrombin time is 16.5 and INR is 2.0 which is abnormal. Amylase serum (115) is abnormal. Skeletal survey shows acute rib fracture to left 8th, healing rib fractures, right 4th and 5th, old rib fractures, right 9th and 10th, chest x-ray otherwise without evidence of active disease, No evidence of pneumonia as a source of infection. No other evident fractures per limited survey of the extremities. CT of brain within normal limits.

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence

Patient is small for his age; Down syndrome features

Mother reports that the patient is not reaching developmental milestones

Diagnosis

Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

T76.1-Child Abuse is when a parent or caregiver whether through action or falling to act, causes injury, death, emotional harm, or risk of serious harm to a child (Camilo et. al., 2016). Child abuse and neglect can have the following consequences physical, psychological, behavioral, and societal (Camilo et. al., 2016).

S39.91XA-Blunt abdominal trauma is secondary to child abuse and is an injury to the abdomen (Hynick et. al., 2014). It may be blunt or penetrating and may involve damage to the abdominal organs (Hynick et. al., 2014). The signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen (Hynick et. al., 2014).

R65.11-Systemic inflammatory response syndrome is used to describe the complex pathophysiologic response to an insult such as infection, trauma, burns, pancreatitis, or a variety of other injuries (Scott et. al., 2014). The five criteria that are involved in SIRS include: - i. Heart rate more than 90 bpm, ii. Systolic blood pressure < 75 mm HG, iii. Respiratory rate more than 20 breaths per minute, iv. Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F) (Scott et. al., 2014) and v. Abnormal white blood cell count >15,500 mm3 or < 6,000 mm3. In T. A.‘s case he presents with 4 out of the 5 criteria putting him the category of having SIRS.

Primary diagnosis:

R65.11-Systemic inflammatory response syndrome.

PLAN including education

T. A. will be sent to the hospital for acute treatment and stabilization. His airway, breathing, and circulation would be assessed. He would be provided with oxygen supplementation for his hypoxia. He will be administered IV isotonic fluid boluses as needed to treat his dehydration. Also, he would be assessed from head to toe to determine how much physical trauma he has sustained during the abuse. Child protective service which includes the police and social work will be contacted to get T. A. to a safe environment where the abuse would stop (Camilo et. al., 2016).

Vaccines administered this visit: none

Vaccine administration forms given: none

Medication-amounts and mg/kg for medications: Fluid resuscitation should be considered. The aim is to restore normal circulating volume and physiologic parameters. Isotonic fluid (20 mL/kg) should be titrated over 5 minutes and repeated as necessary. Supplemental oxygen should be provided, initially at high flow and high concentration.

Laboratory tests ordered: Urinalysis (UA), Amylase, serum, Lipase, PT/INR, Lactic acid, serum, Venous blood gases (VBG), Comprehensive blood count (CBC), Comprehensive metabolic panel.

Diagnostic tests ordered: Skeletal survey, Head CT, Abdominal ultrasound, CT abdomen/pelvis with IV contrast and CT abdomen/pelvis with IV contrast

· Patient education including preventive care and anticipatory guidance: T.A mother’s needs to be educated on current medical condition, possible complication. T.A mother’s needs to be inform why he will to be admitted in PICU for closed monitoring, of his symptoms and treatments.

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· Non-medication treatments: contact security and DCF. Provide hospital security to patient access points. Provide education to parent regarding child abuse and neglect.

·

Follow-up appointment with detailed plan of f/u- The patient is going to need emergent surgical consult and be admitted to PICU for closed monitoring, of his symptoms and treatments. Abdominal injuries are an emergency as the solid organs of the abdomen could be injured and there could be bleeding in the abdomen (Kohler & Chokshi, 2016). The patient should be on a cardiac monitor and a continuous pulse oximetry to monitor vital signs and oxygen supplementation via nasal cannula, IV administered fluids as needed.

Evaluation of Case Study

Child abuse occurs when a parent or caregiver whether through action or falling to act causes injury, death, emotional harm or risk of serious harm to a child (Camilo et. al., 2016). In this case study, it is suspected that the mother’s boyfriend may be the perpetrator of child abuse. There are certain identified risk factors that occur more frequently in parents who abuse their children for example a single-parent family that include an unrelated partner, the partner is frequently the abuser (Merrick & Latzman, 2014). The fact the boyfriend is not related to the child this makes his more likely the abuser. Another risk factors for child abuse are a young age, particularly birth to three years of age, and a child who ill (Merrick & Latzman, 2014). T. A. is identified with several risk factors that makes him more susceptible to child abuse such as his Down’s syndrome, his age which is 26 months, and the fact that his mother is single with three children to support on a low income. Based on her low income, she is unable to afford daycare causing her to have to depend on her boyfriend and neighbors for child care. The mother also admits that her boyfriend is reluctant to provide child care because the children are whining.

The blunt abdominal trauma is secondary to the physical abuse the child is subjected to. Based on the mother’s description of the fall with physical findings, a fall from the crib which would be approximately a 3 feet fall would result in a head or extremity trauma not a 10 cm oval abdominal bruise. Also, the fact that it took two days before the patient’s mother sought medical intervention, the suspicion that there is some form of physical abuse is more apparent. Infants and small children require constant attention and must have all their needs met by others. This can result in parental or caretaker fatigue with resultant striking out at the child with physical force, shaking the child, or ignoring the child’s needs (Merrick & Latzman, 2014). The physical and emotional demands placed on the parents or caretaker of an unwanted, brain-damaged, hyperactive, or physically disabled child may overwhelm them, resulting in abuse (Merrick & Latzman, 2014). Disabled children may not understand that abusive behaviors are not appropriate, so do not tell others or defend themselves (Merrick & Latzman, 2014).

Another important finding based on the mother’s report are that the child is not eating or drinking and has vomited once, his urine output has decreased and is dark in color with an odor, he has not had a bowel movement in a while, he is listless, and not his usual happy self. These findings are linked to circulatory and neurologic compromises which are apparent with shock. One of the other diagnoses for this case study is systemic inflammatory response syndrome which is used to describe the complex pathophysiologic response to an insult such as infection, trauma, burns, pancreatitis or a variety of other injuries (Scott et. al., 2014). From the five criterions that are necessary to diagnose this syndrome, the patient had four of them which were heart rate greater than 90 bpm, systolic blood pressure less than 75, respiratory rate greater than 20 breaths per minute, and white blood cell count of 19,000 mm3 (Scott et. al., 2014). The child is also experiencing hypotension, tachycardia, lethargy, and signs of dehydration shown with his dark urine and decreased urine output which are other concerning symptoms.

This patient needs to be treated immediately as this is a severely ill child. He will need to be treated for his SIRS at the hospital and the monitored in an intensive care unit. After the child is treated and is stable, a complete physical assessment should be completed, and social services should be called in to put him in social care as there are obvious signs of abuse such as old and new broken ribs, old and new ligature marks, and inconsistent historical medical reports from his mother. Physical consequences, such as damage to a child’s growing brain, can have psychological implications, such as cognitive delays or emotional difficulties. Psychological problems often manifest as high-risk behaviors. Depression and anxiety for example, may make a person more likely to smoke, abuse alcohol or drugs, or overeat (Young & Widom, 2014). High risk behaviors, in turn, can lead to long-term physical health problems, such as sexually transmitted diseases, cancer, and obesity (Young & Widom, 2014). While not all children who have been abused or neglected will experience long-term consequences, they may have an increased susceptibility (Young & Widom, 2014). Ensuring that T. A. is removed from his present home and placed in a therapeutic environment is important for his overall well-being and health outcomes.

References

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2013).

Pediatric Primary Care, 6th (Ed). Elsevier, Philadelphia.

Camilo, C., Garrido, M. V., & Calheiros, M. M. (2016). Implicit measures of child abuse and neglect:

A systematic review. Aggression and Violent Behavior, 2943 – 54

Hynick, N. H., Brennan, M., Schmit, P., Noseworthy, S., & Yanchar, N. L. (2014). Identification of blunt

abdominal injuries in children. Journal of Trauma and Acute Care Surgery, 76(1), 95 – 100.

Kohler, E .J. & Chokshi, K.N. (2016). Management of abdominal solid organ injury after blunt trauma. Pediatric

Annals, 45 (7) 241-246.

Merrick, M. T., & Latzman, N. E. (2014). Child maltreatment: A public health overview and prevention

Considerations. Online Journal of Issues in Nursing, 19(1), 1.

Scott, H. F., Donoghue, A. J., Gaieski, D. F., Marchese, R. F, & Mistry, R. D. (2014). Effectiveness of

physical exam signs for early detection of critical illness in pediatric systemic inflammatory

response syndrome. BMC Emergency Medicine, 14(1), 1 – 14.

Young, J. C., & Widom, C. S. (2014). Long-term effects of child abuse and neglect on emotion

processing in adulthood. Child Abuse & Neglect, 38(8), 1369 – 1381.