AM is a 3-year-old Female in Daycare Soap Note

AM is a 3-year-old Female in Daycare Soap Note

AM is a 3-year-old Female in Daycare Soap Note

You have been provided with a scenario on a 3-year-old who is sick and you’ve been provided with a SOAP template. You will read the Scenario, take the information that you’ve been given and place it in the correct space in the Subjective information on the SOAP template. You will have no significant objective details and this portion of the Form will remain blank. You will look at the information and determine what additional information would you like to know. You will write questions on the SOAP note (in a form that you would pose to a patient) to gather more information. You will determine 2 primary diagnosis and complete Pertinent positive/negatives, a patho/rationale/ICD10 codes/plan for EACH diagnosis.

I would encourage you to form your primary diagnosis from the history that you’ve been given (80% of your diagnosis is normally obtained from your history and then confirmed by your exam). You will google search the icd 10 codes, don’t buy a program (this will come along further in the program). Then you will research the patient symptoms and the most common causes of the illness. I would encourage you to then consider the most common diagnoses, then research how you illicit or distinguish these from your primary diagnosis as well as from each other. You will then pose additional questions in the history/subjective and ROS. You will then develop Pertinent positive/negatives, a patho/rationale/ICD10 codes/plan for EACH differential diagnosis.

This is a step process, this assignment will look at focusing your subjective components of the SOAP note, and we will add objective components with the next assignment. I do not want you to make assumptions, you will be asking questions as you would pose to the family or patient. Please don’t tell me “ask about immunizations”, write the question and how you would ask it. This gives you a chance to practice asking questions before you get put in front of the patient in a live situation. On this assignment some students have a hard time getting away from narrative, so it has the OPTION for a 2nd form to allow you to transition. You may put ALL your information on the SOAP note but if that is hard for your then you may submit the second word document.   With the HEENT assignment we will only use the SOAP note.

Mixed up Subjective Data Work Sheet and Case Study

A.M. is a 3-year-old female who is presenting to your primary clinic setting with her mother.  AM. is an existing patient, and she is here for a sick visit.  Her complaint is “fever and sore throat.”

Vitals:   Temp:  38.9 C

HR: 128

RR: 24

BP: 100/72

Height: 32 inches

Weight: 15 kg

  1. Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.  Use only the information provided.
    1. Decide what is pertinent and then place the components in the correct sections of subjective and objective components
    2. Use appropriate abbreviations and concise terminology if appropriate
  2. Consider the following questions
    1. What type of history will you obtain for this visit?
    2. What additional history would you obtain from the family that is significant to A.J.’s situation
    3. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
  3. The SOAP note must include
    1. Medical Diagnosis, 2 primary
      1. Provide pathophysiology/Rationale/Plan (1 paragraph each)
      2. ICD 10 code
    2. Differential diagnosis, 3-5 Differentials
      1. Provide pathophysiology/Rationale/plan (1 paragraph each)
      2. ICD 10 code
  • Health maintenance/risk profile (if appropriate for the visit type)
  1. Pertinent positives (2 for each diagnosis, Primary and differential)
  2. Pertinent negatives (2 for each diagnosis, Primary and differential)
  1. Reference list (you should be researching your diagnosis, so 2 references are expected)
  2. APA format

 

AM is a 3-year-old female, in daycare. AM was in her normal state of health until 3 days ago when she came home from daycare with a mild runny nose. Her mother notes that over the past 3 days the nasal drainage has increased, she has developed a cough, and sore throat, her voice has changed, and last night she had a low-grade fever (tactile) when she came home from day care.  During the night she woke with up crying and hot, mom noted that her temperature was 103.1 (taken under her arm) and she gave her Motrin (7 ml), and she was restless but went back to sleep.  This morning the child woke up later than normal, has not had her normal energy, has had about 2 ounces of milk, no food intake today, she is irritable and just wants to be held.  Nasal drainage stated as clear but today was yellow and thick, she is needing help blowing her nose, her nose is red and irritated, and when mom tried to wipe her nose the child deflects and runs to the chair in the clinic.

Mom called the clinic this morning for a sick visit.  The temperature came down some after the Motrin, but the child feels hot again at time of visit.  No vomiting or diarrhea with these symptoms. No rash

AM was the first child born to this couple, she was a term birth, and since the family has had a set of twins who were premature and required extensive NICU time (and just last week the second infant came home with a g-tube and oxygen).  The mom is very concerned about the infant who is home with her mother but is the first time she has left the infants.  She is anxious to get a prescription and get out of the clinic today.  AM has been in daycare since she was 6 months, but in the past month had to move to a new day care (one that will eventually take all 3 children in the family), since the day care move mom has noted regression, more baby talk, she bit someone recently at school.

AM has is up to date per the mom on her immunizations (for her age), has never been hospitalized, no surgeries, does not take medications routinely, and has no allergies. AM was seen in clinic 2 months ago for her 3-year-old well child and has had routine well exams since birth in this clinic and intermittent sick concerns, mainly respiratory in nature, and one visit for a fall.

The family lives upstairs in a 2-bedroom apartment, it is tight right now with the twins, and mom was working before she got pregnant, but is now having to stay home.  Dad works outside the home in retail and is gone long hours.  No parental smoking.  Mom gives AM Tylenol and Motrin if needed (but does not know the amount that she should give for AM’s weight).  AM eats a toddler diet, drinks from a cup, speaks well with her friends and family, is normally playful, but lately has had a harder time at this new school and has been very clingy and hard to get her to go into the school in the mornings, she cries more recently.

AM’s mom and dad are married, with now the 3 children, no health issues are verbalized by parents, no one else in the home has been sick.  AM’s mom says that her friend’s child who is in the same class was given an antibiotic for the same symptoms last week, and she is better so they just need a quick visit to get the antibiotic and she will need to get home soon to relieve grand mom.

AM is a 3-year-old Female in Daycare Soap Note Assignment Rubric

mixed up soap rubric

  • Description
  • Rubric Detail
  Levels of Achievement
Criteria Excellent Competent Novice Needs Improvement
Case Study Completion

Weight 5.00%

100 %

Student is at ease with the information and appropriately understands and displays ability to process the information from the scenario

75 %

unable to process the information from exam finding, displays lack of synthesis of case study information, student is unable to elaborate or provide additional details

50 %

Student understands the information but is unable to provide basic details

0 %

Student does not display ability to provide basic information

Formating/ use of soap note template

Weight 5.00%

100 %

Appropriate Use of the Form AM is a 3-year-old Female in Daycare Soap Note

75 %

Competent use of the form

50 %

Basic use of the form

0 %

Inadequate use of the form

Subjective

Weight 30.00%

100 %

Appropriately documents the Subjective components from the case study material, Review of systems (ROS)is completed appropriately, 3 HPI, 3 or greater ROS, 2+ Past/Social/Family History item

75 %

one error in completion of the form, subjective components are missing, or mixing of subjective/objective components, lack of Review of system components or Review of system components are inappropriate or mixing of physical 2 HPI, 2 ROS, 1 Past/Social/Family History

50 %

greater than one error or Inappropriate completion of the form, subjective components are missing, or mixing of subjective/objective components, lack of Review of system components or Review of system components are inappropriate or mixing of physical

0 %

Incomplete or missing components

Medical Diagnosis/ Rule Outs/ Health Profile/ Pertinent positives/ Pertinent negatives/ Diffenentials/ Alteration in health prevention

Weight 30.00%

100 %

Appropriately completes the components and displays synthesis of information in the appropriate sections

75 %

on error or inappropriately labeled/mixed or general lack of synthesis of information provided

50 %

greater than one error, Components are missing or inappropriately labeled/mixed or overall lack of synthesis of information provided

0 %

Incomplete or missing components

Plan/ Rationale/ Patho

Weight 30.00% AM is a 3-year-old Female in Daycare Soap Note

100 %

Appropriately completes the components and displays synthesis of information in the appropriate sections

75 %

One error or Components are missing or inappropriately labeled/mixed or General lack of synthesis of information provided

50 %

Greater than one error, Components are missing or inappropriately labeled/mixed or overall lack of synthesis of information provided

0 %

Incomplete or Missing Components

 

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