SOAP NOTE pediatric Jason

Name: Jason Date: 06/09/2020 Time: 0900 Age: 12 days Sex: Female SUBJECTIVE CC: Patient’s mother states patient has mucous filled, bloody stools with inconsolable crying for several days HPI: 12 day old in ...

Name: Jason Date: 06/09/2020 Time: 0900 Age: 12 days Sex: Female SUBJECTIVE CC: Patient’s mother states patient has mucous filled, bloody stools with inconsolable crying for several days HPI: 12 day old infant who arrived to his pediatrician with nonbilious, non bloody vomiting for the past two days. His episodes began two days ago. Patient’s mother changed up his formula which did not relieve his symptoms. One day later he had mucous and blood in his stools accompanied with inconsolable crying. The patient was brought to his pediatrician where an abdominal film was obtained and showed right lower gas paucity concerning for intussusception. Patient was then referred to the emergency department. A contrast enema and abdominal ultrasound was completed, ruling out an intussusception. Patient was admitted at 0300 for inpatient observation. Medications: no current medications PMH: No past medical history Allergies: No known drug, food, or environmental allergies Medication Intolerances: No apparent medication intolerances Chronic Illnesses/Major traumas: Patient denies chronic illnesses and/or major traumas Hospitalizations/Surgeries: no previous hospitalizations or surgeries Family History: 1. Father: Living, no known medical history 2. Mother: living, no known medical history Social History: ROS General: Overall AF is well appearing, denies any, chills, sweats, or fatigue. She is able to carry out her daily activities and attend work as scheduled. No weight changes. Cardiovascular: regular rate and rhythm. No murmurs or gallops. Skin Warm, pink skin tone Respiratory Lung sounds are clear and without adventitious sounds Eyes: pupils are round and reactive to light Gastrointestinal: Normal active bowel sounds in all four quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac arteries. Liver and spleen is not enlarged. She had no rebound tenderness or guarding. Ears Pearly gray tempanic membrane, non- bulging, freely mobile with mild cerumen, no exudate present Genitourinary/Gynecological: Denies any dysuria, hematuria, polyria, incontinence, discharge or flank pain. Nose/Mouth/Throat nose is midline and patent, uvula is midline, oropharynx is symmetrical Musculoskeletal: 2+ radial and dorsalis pulses no clubbing, cyanosis or edema. Full range of motion in her shoulders, elbows, hands, hips, knees and ankles without pain tenderness or swelling. No scapular tenderness. Breast Patient reports a lump at the right breast in the upper right quadrant Neurological: CN 2-12 intact. Strength 5/5 bilateral upper and lower extremities. Deep tendon reflexes 2+ throughout. Romberg normal, gait normal. Heme/Lymph/Endo: no swollen glands Psychiatric: Patient denies any history of psychiatric illnesses OBJECTIVE Weight 7lbs. 10oz Temp 98 BP 75/45 HR 145 Height: 5’7” Pulse: 72 Resp: 18 General Appearance: Well-developed infant, sleeping comfortably, wakes with examination. Skin: No pallor, mild jaundice, no rashes. Breast Exam: Inspection: no dimpling or abnormalities noted upon inspection Palpation: Right breast: palpated small nodule on right breast at 3’oclock position; freely mobile, tender, approx. < 1cm in diameter. Left breast: denies tenderness, pain, no abnormalities noted. HEENT Anterior fontanel open, soft and flat. Red reflex present bilaterally. Palate intact. Cardiovascular: Slightly tachycardic but normal S1, S2, no murmur, strong pulses, capillary refill: 3 seconds. Respiratory: Normal work of breathing with normal breath sounds Gastrointestinal: Slightly distended but no focal tenderness. No palpable mass or organomegaly. Normal anus. Bowel sounds present. Genitourinary: Bladder is non-distended; no CVA tenderness. Musculoskeletal: No deformity, normal tone Neurological: Normal reflexes for age. Psychiatric: Alert and oriented. Lab Tests NONE Special Tests • Contrast enema: Impression: Negative for intussusception (No intussusception visualized, some abnormalities noted in the description but impression says negative for intussusception) • Abdominal ultrasonography: Impression: No masses and no evidence of intussusception • Upper GI Series Differential Diagnoses Intussusception Intussusception presents with a classic triad of vomiting, abdominal pain, and bloody stool in a previously healthy infant (Marsicovetere, Ivatury, White, & Holubar, 2017). The stools are often described as 'currant jelly' stools (Marsicovetere, Ivatury, White, & Holubar, 2017). The abdominal pain is recurrent attacks of severe, colicky pain and often, the infant draws up the legs to the abdomen during the attacks (Marsicovetere, Ivatury, White, & Holubar, 2017). The symptoms may resolve spontaneously but may recur days to weeks later. Most commonly, intussusception occurs in infants aged 5 to 10 months (Marsicovetere, Ivatury, White, & Holubar, 2017). Intussusception is extremely rare in the neonatal period (Marsicovetere, Ivatury, White, & Holubar, 2017). Positives: Abdominal distension, bloody stools Negatives: Severe abdominal pain, colicky pain, drawing of the legs • Milk protein-induced enterocolitis Milk protein allergy generally occurs in infancy, after the introduction of formula into the diet (Nowak-Węgrzyn, 2015). The symptoms include vomiting and diarrhea with variable degree of severity (Nowak-Węgrzyn, 2015). Most infants only have vague symptoms of irritability or 'colic' due to nausea and abdominal pain (Nowak-Węgrzyn, 2015). Symptoms are generally chronic with failure to thrive and protein malnutrition, but can have an acute presentation when complicated by acute enterocolitis (Nowak-Węgrzyn, 2015). The infant with enterocolitis can become dehydrated and lose weight (Nowak-Węgrzyn, 2015). Stools almost always are occult blood positive but grossly bloody stool may be the prominent feature and severe in a few cases (Nowak-Węgrzyn, 2015). Positives: Bloody stools Negatives: Patient does not experience vomiting, diarrhea, irritability • Necrotizing enterocolitis (NEC) Necrotizing enterocolitis (NEC) typically occurs in the second to third week of life in premature, or low birth weight formula-fed infants (Alganabi, Lee, Bindi, Li, & Pierro, 2019). It can have variable manifestations, depending on degree of injury and whether it has progressed to intestinal perforation (Alganabi, Lee, Bindi, Li, & Pierro, 2019). The baby generally appears 'sick' or 'toxic', may have fever or hypothermia and signs of shock (Alganabi, Lee, Bindi, Li, & Pierro, 2019). Abdominal distension is significant with hypoactive or absent bowel sounds (Alganabi, Lee, Bindi, Li, & Pierro, 2019). Positives: Mild distention Negatives: Patient does not show signs of significant distention, fever, signs of shock hypothermia or absent bowel sounds Diagnosis: Midgut volvulus may occur at any time in the first few years of life, but must be suspected when a neonate presents with symptoms and signs of intestinal obstruction (Ahmadi, 2019). It occurs when the intestines become twisted as a result of malrotation of the intestine during fetal development. The malrotated bowel is prone to torsion, which can lead to midgut volvulus (Ahmadi, 2019). Classically, volvulus presents with bilious vomiting and high intestinal obstruction (Ahmadi, 2019). This is a 'do not miss' diagnosis and must be excluded. Positives: Abdominal distention, bloody stools, sleepy, lethargic Negatives: Severe abdominal pain, patient does not have bilious vomiting