Nurse Practitioner SOAP Notes

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The SOAP Note entails the details gathered from a pediatric patient aged 12 years who visited the hospital for a clinical intervention.The patient under treatment complained of stomach ache and an associated fever. She also complained of sore throat and his brother had streptococcus a week ago.

SUBJECTIVE DATA:

            Chief Complaint (CC): Fever

History of Present Illness (HPI):

Onset The patient started complaining of stomach ache and fever the same day he was brought to the hospital
Location Stomach, throat, and ears
Duration One day since the morning hours
Characteristics Stomach ache, fever, sore throat
Aggravating Factors Stomach ache and sore throat
Relieving Factors No complain of ear ache, congestion, coryza, cough, chest pain, wheezing, nausea, and vomiting
Treatments/Therapies Throat culture and symptomatic treatment for pain and fever

Medications:No prior medication before clinical visit

Allergies: No allergies

Past Medical History (PMH): His brother was diagnosed and treated for streptococcus a week ago

Past Surgical History (PSH): N/A

OB/GYN History: (if applicable) N/A

Personal/Social History:the patient does not have problems with his body temperature changes, is social and active, does not comment about his health condition

Immunizations: Hepatitis, Influenza, Measles, mumps, Meningococcal, Tetanus, and Pneumococcal polysaccharide

Family History:There is no history of fever, but her brother was diagnosed and treated for streptococcus a week earlier.

Review of Systems:

General: The patient looks well and in no acute distress

Skin: Normal

HEENT:TMs translucent with good landmarks, Eyes not sunken, with tears, and non-injected, cheeks red, little nasal congestion

Neck: No adenopathy

Breasts:Normal

Respiratory:Sore throat, No cough, wheezing or chest pain.

Cardiovascular:regular rate and rhythm

Genital: N/A

Endocrine: Normal

OBJECTIVE DATA:

Vital Signs: BP 92/60Temperature 101.2 Weight 50 pounds

General: The patient looks well and in no acute distress

SKIN: Normal

HEENT:Cheeks were rather red, Tympanic membranes appear normal bilaterally, some nasal congestion, oropharynx showed no redness, exudates, swelling, or tonsillar enlargement

Neck: No neck adenopathy

Chest/Lungs:Lungs were clear to auscultation and with good breath sounds, No rales, rhonchi, or wheezes

Heart/Peripheral Vascular:regular rate and rhythm, No murmur

Abdomen: Exam was normal

Genital: N/A

Musculoskeletal: Normal

Neurological: Normal

ASSESSMENT:

Diagnosis Positives Negatives Rationale & Reference
Viral Pharyngitis Sore throat, sneezing, nasal congestion, Fever,   The disease is likely to be in the common cold syndrome.
Focal infection   Sore throat Usually appears as sore throat in the tonsils
Diphtheria Upper respiratory infection   Usually cause by bacteria called aerobic-gram-positive and hence not a likely primary diagnosis

 

Lab/Imaging (Results) Patient results Rationale
Rapid strep Negative The throat swab takes less time and can show the presence of group A streptococcus bacteria. It causes strep throat and other infections

Holistic Care

Chronic Condition Status Plan
No chronic condition present    

 

Lab/Imaging (Results) Patient results Rationale
N/A    

 PLAN:

Condition Pharmacological Nonpharmacological

Alternative Treatments

Test Follow up

Referral

Rationale
Viral Pharyngitis Treatment for pain and fever using pain relievers and Acetaminophen for fever Checking the throat culture to ensure that the condition is not strep Throat culture and Rapid strep test Follow up of other significant changes in the patient condition The method is appropriate to check the cause of the sore throat and fever

Health Promotion:Body temperatures vary from time to time, but have optimum levels during which an individual is stable. As such, any suspecting body temperature should be checked and addressed as required.

Disease Prevention: Screening is crucial for a normal well being. As such, there ought to be sensitization programs to the community regarding the importance of early screening for all unusual body temperatures to avoid serious infections that appear as fever.

REFLECTION:

As included in the SOAP note, the patient under treatment complained of stomach ache and an associated fever. She also complained of sore throat and his brother had streptococcus. It is surprising to realize that the patient suffered from viral Pharyngitis in the common cold syndrome which does not exhibit sore throat as the primary symptom. Thus, the diagnosis is more based on nasal symptoms and the slight fever other than the sore throat. The diagnostic process is appropriate for the disorder identified, but ought to be more comprehensive to ascertain it. Most of the results from the review of systems are normal that raises concerns of the identified disorder. However, the process used was successful in addressing the patient problem.

References

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013) Pediatric primary             care (5th ed.). Philadelphia, PA: Elsevier.

Gagan, M. J. (2009). The SOAP format enhances communication. Kai TiakiNursing New Zealand, 15(5), 15

Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health    supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).      Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.

Shulman, S. T., Bisno, A. L., Clegg, H. W., Gerber, M. A., Kaplan, E. L., Lee, G., … & Van         Beneden, C. (2012). Clinical practice guideline for the diagnosis and management of      group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of   America. Clinical Infectious Diseases, cis629.



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