2) ICD 10: S39.91XA – Unspecified injury of abdomen, initial encounter (CDC, 2017). Bruise present to epigastric area, mother related she noticed it at 1430, mother related pt fell out of bed 2 days ago per her boyfriend, pt has increased respirations, increased heart rate, decrease appetite, decreased urine output, and is responsive to painful stimuli. 3) ICD 10: S09.90XA – Unspecified injury of head, initial encounter (CDC, 2017). Mother relates pt fell out of bed 2 days ago, per her boyfriend, unknown if pt hit their head. Mother relates pt has not been acting to their norm, has decreased appetite, decreased urine output, and bruise to abdomen. Pt responsive to painful stimuli. PLAN including education PLAN including education Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. Include EB rationale for all aspects of your treatment plan: Vaccines administered this visit Vaccine administration forms given Medication-amounts and mg/kg for medications Laboratory tests ordered Diagnostic tests ordered Patient education including preventive care and anticipatory guidance Non-medication treatments Follow-up appointment with detailed plan of f/u 6 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE An NG tube will need to be placed to possibly help alleviate the abdominal distention. A Foly catheter will need to be placed to closely monitor input and output. Patient will need to be admitted to facility ICU for further treatment and monitoring (at an appropriate pediatric hospital). DCF will need to be contacted immediately as well as hospital case manager/social services. A surgical consult for possibly emergency surgery is warranted (Peterson et al., 2015). Patient will need additional labs and imaging as needed as his condition changes. References Centers for Disease Control and Prevention. (2017). ICD-10 Mortality 2e Volume 1 – 2017. Retrieved from: Chiocca, E.M. (2014). Advanced pediatric assessment, (2 nd ed.). Springer Publishing Company Peterson, M.L, Abbas, P.I., Fallon, S.C., Naik-Mathuria, B.J., & Rodriguez, J.R. (2015). Management of traumatic duodenal hematomas in children. J. Surg. Res , 199 (1), 126- 129. DOI: 10.1016/j.jss.2015.04.015 7 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE *ALL references must be Evidence Based (EB) 8 | P E D I A T R I C S O A P N O T E
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- Spring '18
- Down syndrome, Trigraph, ICD-10, Medical diagnosis, Bruise