Genitourinary No CVA tenders Tanner stage II Musculoskeletal ROM intact no

Genitourinary no cva tenders tanner stage ii

This preview shows page 6 - 9 out of 11 pages.

Genitourinary: No CVA tenders. Tanner stage II. Musculoskeletal: ROM intact, no difficulties. Ambulates steady, no wobbling or leaning. Neurological: AAOx4. Calm. Cooperative. Spine midline, no difficulties with ROM. Posture erect. Behavioral/Psychiatric: Alert and oriented. Hair well groomed. Calm during interview, able to sit still and quietly. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Image of page 6
Pediatric SOAP Note Pediatric/Adolescent Assessment Tools: HEADSS- H- Home- Lives at home with mother and father. Never home alone. E-Education- Currently in the 4 th grade. Able to read and write appropriately. A-Activities- No sports at this time. Rides bike with helmet around neighborhood with parents. D-Drugs- No illicit drug usage S-Suicidality- Happy, calm. No suicidal ideations/attempts S-Sex- No sexual contact. Patient knows to not allow others to look at genital area besides medical professional and parents if there is a problem Present Developmental: Child developmentally appropriate. Erikson’s stage- Industry vs. Inferiority. Lab and/or Diagnostic Tests: Influenza A swab- Negative Influenza B swab- Negative Rapid Strep test swab- Positive DIAGNOSIS Instructions: Primary Diagnosis: Streptococcal Pharyngitis J02.0 This is an infection caused by group A Streptococcus. It is an infection of the oropharynx. The patient presented with the common symptoms of sore throat and fatigue. On clinical examination the patient presented with pharyngeal erythema without exudate. (CDC, 2018). Differentials: Acute Nasopharyngitis J00 Acute Nasopharyngitis is also the “common cold.” This is a viral infection that affects the upper respiratory tract. The patient is a school aged child which increases her risk for the development of the common cold. The patient presents with common signs and symptoms of such as, cough, sore throat, congestion, and fatigue. The patient presents with a clear nasal discharge which can also be associated Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Image of page 7
Pediatric SOAP Note with the common cold. (Medical Joyworks, LLC, 2019). Otitis Media, Left Ear H66.92 Otitis Media is the infection or inflammation of the middle ear. This is typically associated with a cold, sore, throat, or respiratory infection. Currently the patient is positive for strep throat. (John Hopkins University, 2019). Final/Primary Diagnosis (es): Streptococcal pharyngitis J02.0 PLAN: Medication: Amoxicillin 500 mg 2 tablets by mouth twice a day for 10 days. Pharmacological treatments: Amoxicillin 500 mg 2 tablets by mouth twice a day for 10 days. Patient education to use over-the-counter medication, Tylenol. Children’s Tylenol liquid suspension 160 mg/5ml. Patient educated to use 4 teaspoons every 6 hours as needed for pain management. (Tylenol, 2019). Non-Pharmacological treatments: Patient educated to use warm, salt water gargles for pain management. Patient educated to use cough drops to help with cough and throat pain. Patient and father educated about the use of hot tea, honey, and chicken noodle soup. Patient and father educated that patient may return to school after 24 hours of starting Amoxicillin. Patient educated about the importance of frequent handwashing and good handwashing techniques. The patient is educated to
Image of page 8
Image of page 9

You've reached the end of your free preview.

Want to read all 11 pages?

  • Summer '17
  • cough, Common cold, nasal congestion

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes