SOAP Note week 6 final

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SOAP Note week 6 final Dr. and class Patient Information: M.S., 10 year old, male, Insured Subjective Data CC: unusually tired HPI: Presents to clinic with his mother who states 2 or mo... re weeks ago she noticed patient has not been himself. Unusually tired, no energy, sleeping more, never hungry, some weight loss, always thirsty, wet to bed last week. He does not want to play outside and says he cannot keep up with the other kids in gym class. Reports feeling dizzy at times. Has had a cold but seems worse than the rest of the family. Current Medications: Daily multivitamin Allergies: Penicillin PMHx: Mother reports patient in good health, no childhood or chronic illnesses. No surgeries or hospitalizations. Sleeps 8-10 hours nightly. Soc Hx: He is the oldest of 4 children. Is a good student, lives at home with his parents, grandparents, siblings and 2 dogs and a cat. Fam Hx: Parents and siblings are in good health. Maternal grandparents both have history of HTN and hyperlipidemia. Paternal grandparents are deceased. Paternal grandmother had brain cancer and paternal grandfather had leukemia. ROS Constitutional: Denies fever, chills, nausea or vomiting. Complains of dizziness, and weight loss. HEENT: Denies any headaches, does complain of occasional dizziness. Denies any visual changes, ear pain, hearing loss or ringing in the ears. No reported nasal congestion or discharge. No reported sore throat, or difficult swallowing. Cardiovascular: Denies chest pain or discomfort. No reported palpitations. No reported cardiac history. Respiratory: Denies respiratory complications such as cough, difficulty breathing, and shortness of breath or wheezing. Gastrointestinal: Denies heartburn, indigestion, or abdominal tenderness. Lymphatics: Denies any enlarged lymph nodes or tenderness. Neurological: Denis any numbness or tingling. Denies any problems with balance or ambulation. Objective Data Vital signs: Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16 BMI 23.8 Constitutional: Patient is alert, oriented and cooperative, but appears tired and distracted. No fever, no nausea or vomiting. HEENT: Head: normocephalic, hair thick and evenly distributed throughout scalp. Eyes: sclera clear, conjunctiva white, PERRLA. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and targus non-tender. Nose: Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck: supple, thyroid midline, small and firm without palpable masses. Skin: Pale pink, no cyanosis observed, cool, dry and intact. No alterations noted no moles or skin changes observed. Cardiovascular: Heart S1S2, RRR w/o murmur. No palpitations. Respiratory: Lung sounds are clear bilaterally. Respirations even and unlabored. Gastrointestinal: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. Lymphatics: No cervical lymphadenopathy noted. Neurological: reflexes WNL, gait steady, no noted memory problems. Assessment: Hyperglycemia unspecified (stress hyperglycemia) (ICD-10 R73.9)-Approximately 5% of children who present to the ER or clinic with an acute illness or chronic illness suffer from high glucose levels which are not due to a diagnosis of diabetes but due to their current illness, this could range from something as minor as an URI to “acute illness/sepsis; traumatic injuries, febrile seizures, burns, and elevated body temperature”, (Craig, Jefferies, Dabelea, Balde, Seth, & Donaghue, K. C. 2014). Mary stated that Michael has had a cold just like the rest of the family but that his has been worse. Acute illness can cause the same symptoms that a person diagnosed with diabetes has. It is important to assess the patient for potential underlying condition and if found the condition needs to be treated. This patient was reported to have a cold. The labs are normal therefore there is no sign of any bacterial infection. If it is viral there is no treatment available. Testing results: CBC: WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5- WBC within normal values, Hgb normal values 11-16, Hct normal values 31-43%, RBC 3.8-5.5, MCV normal values 82-92, MCHC normal value 0.32-0.36, and RDW normal 11.5-14.5, (LeFever Kee 2013). ...............Continued...... [Show More]

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