Portfolio of Dalya Tobea



King University MSN/NP Program 42386250 Clinical SOAP Note Format PediatricsDalya TobeaSOAP Note #2Initials: T.H, maleAge:9 years old DOB: 1/22/2007 Erickson’s Developmental Stage: Industry versus Inferiority. This is the stage where the child adapts to their environment and achieve goals or the child might be restricted and not reach his/her potential(S) CC: Diarrhea and abdominal cramping for 11 months referred by pediatrician HPI: Pt presents with his mother and father in the office with diarrhea and abdominal cramping intermittently for the past 11 months. The cramping usually stays in the bilateral lower abdomen but can include the upper quadrants. The pain is rated 5-6/10 of severity. The cramping will last for hours. The pain does not wake the patient up at night. The mother noted that the pain and diarrhea is worse after the pt eats pizza or sandwiches. The cramping and diarrhea improves when the patient eats steak or vegetables. Pediatrician prescribed omeprazole 40 mg PO QD which the pt and family stated it did not ease the pain or diarrhea. Pt on average will have 2-3 loose stools per day. Pt will need to use the bathroom an hour after each meal. The mother rates the stool to be type 6 on the Bristol stool chart. It is brown, without evidence of bleeding. Pt denies fever and chills during this period. Mother stated that pt is passing frequent malodorous flatulence. Abdomen appears distended at times. Pt has nausea at times but not very often or recently. Pt denies vomiting and bloating. Pediatrician ordered celiac series serology such as IgA which is positive for celiac. Family was told to continue to eat gluten until the results are back because gluten is needed in the diet for the testing to be accurate. Medical/ surgical history (including birth history): Birth history was unremarkable. No surgical history. Last physical was 4 months ago by his pediatrician. Pt takes omeprazole 40 mg PO QD. Last visit to the dentist was 8 months ago. Family/Social: Pt lives with his parents and his 12-year-old brother. Pt has a pet rabbit. Pt is in the 4th grade. Pt denies recreational drugs abuse, smoking, or drinking alcohol. Pt and family denies being exposed to toxins or traveling. Pt and family denies any abuse/safety concerns. His mother works at a grocery store and his father is a businessman. Hobbies include playing video games, riding on bike, and watching TV. Pt is not exposed to second hand smoke. There are no guns in the household. Pt exercises about 2-3 times a week by playing outside after school with friends. Pt’s grandmother takes care of the pt and his brother until their mom arrive home at 4 during school days. Father has psoriasis and asthma. Mother has seasonal allergies. Family requires the pt to sit in the back wearing his seatbelt. Pt wears his helmet at times while biking. Pt denies being bullied. House does have smoke alarms. Pt does brush his teeth daily and floss at bedtime. Pt denies drinking caffeine. Pt and family are Baptism and attend church weekly. Pt states he has multiple good friends whom he plays soccer with. Immunization status: Pt is up to date on all immunizations. Educated mother that a flu shot will become available to administer starting in September. Pt needs a TB test which can be given at the same time of the flu shot since this office does not have the resources. Meds/Allergies: Pt is not allergic to food or medications. ROS: General: Pt denies fever and chills. Pt reports tired of feeling sick and wants to get better. HEENT: Denies HA, head injuries, dizziness, blurring/double vision. Pt does not wear corrective lens. No post-nasal drip. Pt denies tinnitus. Denies nosebleeds, hoarseness, or sore throat. Scalp is non-tender. No sinus tenderness present on palpation on the frontal and maxillary sinuses.Skin: Denies rash, itching, or pigment/mole changes.Respiratory: Denies SOB, sputum, cough, wheezing, night sweat, or being exposed to TB. Denies dyspnea on exertion.Cardio: Denies chest pain or palpitation. Denies swelling or cool extremitiesGI: See HPI GU: Denies flank pain, urgency, dysuria, or nocturia. Kidneys are non-tender. Diet: Pt has lost 2 lbs. in the past 3 months. Pt stated he has a good appetite but is worried to eat at school because it can cause diarrhea. Last 24-hour diet recall is Breakfast-Cereal with milk Lunch-hamburger sandwich with apple juice Dinner-meatloaf with apple juice. Pt had less than 1 glass of water. Endocrine: Denies heat/cold intolerance. No goiter or pain. No change in skin texture. No heart palpitations or anxiety.MS: Denies swelling/heat in joints.Neuro: Denies fainting. No seizure history, weakness, strokes, or HA. Psych: Denies suicidal/homicidal ideations. (O)T-98 RR-17 Pulse- 101 BP- 90/62 Ht-4ft 3 inches. Wt- 65lbs BMI:17.6 Pain-0/10 currentlyConstitutional: Pt is a 9-year-old Caucasian male accompanied by parents. Pt appears well-dressed and groomed. Pt is playing on his iPad during introduction. Mood and affect are appropriate. Pt has good posture with stable gait. Pt is orientated. HEENT: Head is normcephalic without head trauma. Hair is fine red color. It is clean with even distribution. No masses palpated. Facial features symmetric. Trachea is midline without tug. No JVD or carotid bruits noted. PERRLA. Sclera is white, conjunctivae is pink without discharge. Red reflex is present. EOM intact. No nystagmus present. Septum is midline, nares patent bilaterally. Thyroid is non-palpable. No lymphadenopathy in head or neck. Nasal turbinates’ pink and moist. Lips are symmetry with tongue midline and mobile. Uvula rises with ah. No postnasal drip present. TM is pearly gray without effusion in bilateral ears. Weber test and Rinne test are negative for hearing loss. CN VIII intact utilizing whisper test.Skin: Skin is pink and warm. Capillary refill less than 3 seconds. No lesion or edema noted.Respiratory: Lungs are clear bilaterally. AP is 2:1. No accessory muscles are used. Respirations are unlabored and even. Resonant present on percussion. Tactile fremitus present. Thoracic expansion is symmetric. Cardio: No lifts or thrills present. S1, S2 regular without gallops, murmurs, or snaps. No clubbing or cyanosis. Carotid, brachial, and femoral pulses are + 2 bilaterally. PMI palpated, no heave. No edema noted.GI:Pt has hyper active bowel sounds in all four quadrants. Pt has tenderness on the bilateral lower quadrants on palpation. No masses, lesions, or bruit noted. Contour is flat and symmetry. No distention. Tympany sound is present on percussion of abd. Liver span is 4 cm. Spleen is nonpalpable. No ascites present. Femoral pulses are +2 bilaterally. Inguinal lymph nodes are nonpalpable. GU: NA MS: ROM is strong and equal bilaterally without swelling. Posture is good and aligned. Gait is stable with full ROM throughout all joints. No heat or edema present in any joints Neuro: Cranial nerves 2-12 are intact. Romberg test negative. Rapid alternating movements, and finger to nose test are within normal limits without ataxia. No tremors or unilateral weakness noted. Sensory system intact in bilateral upper & lower extremities as demonstrated utilizing the light touch, temperature, and pain techniques Psych: Orientation is intact. Pt is dressed appropriately. well. Good thought process and content. Pt denies suicidal ideation. Pt denies feeling depressed or anxious. Mother stated that pt handles stress by playing with video games to clear his mind. Mother denies behavioral concerns. Pt is doing well in school. Dx Celiac disease K90.0 DifferentialsIrritable bowel syndrome K58.9Ulcerative Colitis K51.90Diarrhea R19.7Diverticulitis K57.5H. Pylori B96.1Appendicitis K36Crohn’s disease K50.919Lactose Intolerant E73.8C. difficile A04.7(P)Serology results indicate Celica disease concomitant with the pt’s symptoms. EGD with biopsy is the gold standard for diagnosis of this disease. We will schedule this test to be done by next week. I will also order CMP, CBC with diff, PT, serum iron, Vit. B 12 level, and d-Xylose. Depending on the insurance agency, the cost for the EGD is around 2000$. Approximated cost for the serology is around 400$. Education/Anticipatory Guidance: Educate family that the pt will need to avoid all gluten foods, which is the first line of treatment. Gluten is found in wheat, rye, barley, and flour. The pt does not have an allergy to gluten such as being gluten intolerant, rather the patient has an autoimmune disease, which the lymphocytes destroy the lining of his stomach when it is exposed to gluten. This causes increase risk of carcinoma, therefore it is extremely important for the pt to abide by a gluten free diet. Pt should feel better after 7 days when adhering to the diet and symptoms show disappear after 4-6 weeks. I will refer the pt to a registered dietitian as gluten can be hidden in many foods and reinforce foods are good to eat. If symptoms do not improve after 4-6 week then pt will need to return to office. Pt is no longer required to take Omeprazole. Educate family and patient that his nutrition status is not adequate. He needs to be incorporating more vegetables, fruit, and water into his diet. Applauded the parents for reinforcing the pt to sit in the rear of the care with his seatbelt. If pt plays sports or ride a bike, then it is crucial he wears a helmet to avoid injuries. Pt is spending a lot of times indoors and not enough time outdoors exercising. Educated family and pt the importance of daily activity outdoors. Encouraged to spend at least 30 minutes a day outside playing and spend less time playing video games or watching TV. Follow-up instructions: Educated family that pt will need to remain npo after midnight prior to the procedure which the nurse will schedule within the next couple of days. If pt start to have bleeding with diarrhea, fever, or chills then pt needs to go to the ER. Independent Practice Competencies- Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. I treated my patient with respect. I knocked on the door before entering, greeted the pt by her name with a handshake before introducing myself. I allowed the pt to feel safe and comfortable in the exam room by obtaining her history before I performed the physical exam. When I assessment private areas, I informed the patient to ensure trust.Practice Inquiry Competencies - 3. Applies clinical investigative skills to improve health outcomes. I asked appropriate questions to receive my conclusion of the cause of the chief complaint. Quality Competencies- 2. Uses best available evidence to continuously improve quality of clinical practice. I choice the golden standard test for Celiac Disease which is an EGD with biopsy. ................
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