KING UNIVERSITY MSN/NP PROGRAM CLINICAL SOAP NOTE FORMAT PEDIATRICS

Dalya Tobea

SOAP Note #4

Initials: Age: 15 years old DOB: 01/9/2001Erickson’s Developmental Stage: Ego identity versus role confusion. This is the stage where children are becoming more independent and want to fit in with their peers.

(S)

CC: F/U on abdominal cramps

HPI: Pt presented with abdominal cramping and bloat in 07/6/2016 for two months. The pain will last minutes to hours over all four quadrants of the abdomen. The pain is 5-8 out of ten. Pt has BM QOD of semi formed brown stools. Pt reports increase pain after eating sugar and pizza. Pt reports decreased pain after eating vegetables. OTC Tylenol and Zantac did not ease the pain. Pt was negative on H. pylori test and hemoccult. Pt had an EGD and colonoscopy a week ago to assess his symptoms. He is here for F/U of results.

Medical/ surgical history (including birth history): Birth history was unremarkable. No surgical history or past medical history. Pt had an EGD and colonoscopy last month to assess CC. See HPI for current disease.

Family/Social: Pt lives with his mom, stepfather, and stepsister. His stepsister is 8 years old. His mother remarried 3 years ago and he moved in with his stepfather. Pt’s biological father lives in Michigan for work. He visits his father every summer. Household has 4 terrier dogs; the dogs are up to date on the rabies vaccine. Pt denies recreational drugs abuse, smoking, or drinking alcohol. Pt denies being exposed to toxins or traveling. Pt denies any abuse/safety concerns. Pt is not sexually active. Hobbies include playing video games, skateboarding, and eating. Pt is not exposed to second hand smoke. Pt exercises daily playing on his skateboard. There are no guns in the household. Pt watches TV/plays video games approximately 1-3 hours a day. There are smoke detectors in the household. Family carriers Humana insurance. Family is Baptism and attend church as much as their schedule allows them. Mother works at a gas station. Stepfather works as a mechanic. Pt is left alone most days to watch his stepsister after school until a parent arrives home. Pt and stepsister ride the school-bus. Pt tolerates his stepsister, however, he believes he does not have much in common with her. Pt does have several good friends that he skateboards with. Pt denies being bullied or bullying other students.

Immunization status: Pt is up to date on all immunizations. Educated pt that he is due for a flu shot. Flu shots are not offered at this clinic, however, informed pt he can receive the shot at walk-in clinics or go to his pediatrician.

Meds/Allergies: Pt is not allergic to medications.

ROS:

General/Psych: Pt denies fever or chills. Pt denies suicidal ideation. Spoked to mother in private to inquire if she has notice any behavior/temperament concerns, which the mother denies. Pt denies increased stress/anxiety at home or school. Pt copes with stress by riding his bike or playing video games.

HEENT: Pt denies nosebleeds, hoarseness, or sore throat. Scalp is non-tender. No sinus tenderness present on palpation on the frontal and maxillary sinuses. Pt denies HA, head injuries, dizziness, blurring/double vision.

Skin: Pt denies rash, itching, birthmark, 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 extremities

GI: See HPI

GU: Denies flank pain, urgency, dysuria, or nocturia. Kidneys are non-tender

Diet: Last 24-hour diet recall include: Breakfast: eggs and bacon, Lunch: chicken sandwich with water, Dinner: Spaghetti with coke, snacks-fruit snacks.

Endocrine: Pt denies heat/cold intolerance, or change in skin texture.

MS: Denies swelling/heat in joints.

Neuro: Pt denies fainting. No seizure history, weakness, strokes, or HA.

(O)

T-98.8 RR-16 Pulse- 87 BP- 109/78 Ht- 5ft 6in. Wt.- 120lbs BMI:19.4 Pain-0

Constitutional: Pt is accompanied with his mother. Pt appears well and is playing on his iphone. Pt is alert and does not appear in distress. Orientation is intact and tracking provider around the room. Pt is dressed appropriately. Well-groomed.

HEENT: Head is normcephalic without head trauma. Hair is thick and black color. It is clean with even distribution. No masses palpated. Facial features symmetric. Trachea is midline without tug. 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, birthmark, acne 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 normal active bowel sounds in all four quadrants. Pt has tenderness on the epigastric region 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 3 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. No scoliosis. Neuro: Cranial nerves 2-12 are intact. Romberg test negative. No tremors, ataxia, or unilateral weakness noted. Sensory system intact in bilateral upper & lower extremities as demonstrated utilizing the light touch, temperature, and pain techniques.

(A) EGD and colonoscopy results were negative. Dx1. Gluten intolerant

Differentials2. Irritable bowel syndrome K58.93. Short bowel syndrome K574. Crohn disease K50.9195. GERD K21.96. Whipple disease K90.81

7. Tropical sprue K90.18. Gastritis K52.81

(P)Pt is Gluten intolerant based on his symptoms, diet, and diagnostic testing. EGD was performed to rule out celiac disease. Educated pt and mother to avoid gluten food such as wheat, rye, and graham flour. Gluten is commonly found in white bread, flour, and pasta. There are gluten free pasta and bread which the pt can indulge in. Most restaurants have gluten free menu. It is important that pt keeps a food diary to assess if any particular foods cause more pain. I will refer pt to a registered dietician. If symptoms persist after diet modifications, then further diagnostics will be required such as CT, ultrasound, and bloodwork. If I was the provider for this patient, I would have started with diet modification and bloodwork to detect celiac before performing invasive testing.

Education/Anticipatory Guidance: Provided anticipatory guidance on substance abuse, safe sex, peer pressure, bullying, tobacco, and to received plenty of sleep. Pt needs to exercise at least 5 days a week and attempt to decrease the amount of time he spends watching TV or playing video games. Pt needs to drink 5-6 glasses of water daily and to avoid high sugary drinks.

Follow-up instructions: Pt will need to follow up in 8 weeks to reassess pain after diet modification. If pain starts to become sharp, lasting all day, blood in stools, or fever/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.

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. First line of treatment for Gluten intolerant is lifestyle modification.