Assignment NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children
Assignment: NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children
Week 3 SOAP note- Follow up Evaluation
Patient Initials: ___AH____ Age: ___12____ Gender: ___F____
SUBJECTIVE DATA:
Chief Complaint (CC): Episodes of altered mental status, follow up from recent hospitalization
History of Present Illness (HPI): 12-year-old African American female brought to clinic with mother for follow up evaluation after hospitalization. Two days prior, patient was at school with she became altered and had episodes of jerking movements. …
Medications:
…
Imipramine 25mg PO PRN- Mother reports that she occasionally takes this is she drinks a lot prior to bed. Last dose was 1 week prior to event occurring.
Trazodone PRN
Allergies: NKDA
Past Medical History (PMH):
Autism, …
Past Surgical History (PSH): Esophagogatroduodenoscopy …
Sexual/Reproductive History: Denies onset of menarche. Denies any sexual behavior.
Personal/Social History:
Immunization History:
Significant Family History:
Lifestyle:
Review of Systems:
General:
HEENT:
Neck: Denies any tenderness, pain, or swelling.
Breasts: Denies pain
Respiratory: Denies difficulty breathing, or pain.
Cardiovascular/Peripheral Vascular: …
Gastrointestinal: …
Genitourinary: Denies any pain or trouble with urination.
Musculoskeletal: …
Psychiatric: …
Neurological: …
Skin: Denies any rashes or sores.
Hematologic: Denies any bleeding. Mother denies bleeding disorders.
Endocrine: Denies excessive thirst. Mother states that she must encourage child to drink.
Allergic/Immunologic: Patient has seasonal allergies which she takes medication for.
OBJECTIVE DATA:
Physical Exam:
Vital signs: …
General: …
HEENT: …
Neck: Trachea is midline. No JVD. No masses or abnormalities present. Lymph nodes are without enlargement.
Chest: No tenderness on palpitation. No lumps or masses felt. No abnormality noted.
Lungs: Breath sounds clear and equal. Chest rise and fall symmetrical. No wheezes, rales or rhonchi present.
Heart/Peripheral Vascular: …
Abdomen: …
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Labs:
ASSESSMENT:
Diagnosis – Seizure disorder –
- Behavioral issue r/t autism disorder- These symptoms could /…
- Adverse medication effects- …
- Migraine- …
PLAN:
Treatment Plan: …
Health Promotion: …
Disease Prevention: …
REFLECTION:
During this experience, I learned that the patient’s parents are more concerned than the patient. Mother was crying during this visit, feeling depressed regarding patient and the unknown diagnosis. The patient appeared to be well on this examination. However, the patient had numerous health issues, most of which were psychiatric or behavioral. Care must also be given to not only the patient, but family (Burns, et al, 2017). Also, during this experience, I learned that there are so many factors that go into determining a diagnosis for the patient. The symptoms of this patient were complicated, so there are things to rule out prior to an official diagnosis. The children’s hospital was unable to rule these things out prior to the office visit. Follow up evaluation is needed for this patient.
References:
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.
Burns, C. & Matson, J. (2017). An investigation of the association between seizures, autism symptomology, and developmental functioning in young children. Developmental Neurorehabilitation, 21(3). DOI: 10.1080/17518423.2018.1437842.
Eidlitz-Markus, T., & Zeharia, A. (2017). Symptoms and clinical parameters of pediatric and adolescent migraine, by gender- a retrospective cohort study. The Journal of Headache and Pain, 18 (80). DOI: 10.1186/s10194-017-0789-z.
Linke, A., Olsen, L., Gao, Y., Fishman, I., & Muller, R. (2017). Psychotrophic medication use in autism spectrum disorders may affect functional brain connectivity. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2 (6). DOI: 10.1016/j.bpsc.2017.06.008
Pisula, E., Pudio, M., Slowinska, M., Kawa, R., Strzaska, M., Banasiak, A., & Wolanczyk, T. (2016). Behavioral and emotional problems in high functioning girls and boys with autism spectrum disorders: parents’ reports and adolescents’ self-reports. SAGE Journal, 21(6). Doi: 10.1177/1362361316675119.
Important information for writing discussion questions and participation
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource
Welcome to class
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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!