Chamberlain College of Nursing – NR 602Week6. SOAP. SOLVED. GRADED A

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Soap Note: Lily, F, 16y F, Riley, F 24months S: CC: Fever, Vomiting, Diarrhea, Abdominal pain HPI: Kayla (Mom) brings (Lily 16F) and (Riley 24M) to the clinic for several episodes of vomiting for ... 2 days and diarrhea that started the last 24 hours. Both children have a low-grade fever of 100 to 101 degrees. They have not eaten solid food since they ate from a pizza buffet 36 hours ago. They have been drinking sprite, apple juice, and popsicles, and keeping fluids down. Mom reports that both children voided this morning. Mom reports that Lilly has not vomited today, however, Riley vomited twice this morning in small amounts. Lilly reports lower abdominal pain that started this morning, she reports starting her menses today. Lily is complaining of headache, and myalgia. Her pain is 5 on a 1-10 scale and has progressed in the last hour. Mom reports giving acetaminophen and Pepto-Bismol OTC 2-3 times a day and Riley vomited after his dose this a.m. (Lily: Diarrhea, vomiting. O: When did the vomiting and diarrhea first start? (Vomiting the last 2 days, diarrhea past 24 hours). L: Are you having vomiting and diarrhea simultaneously? D: How long does the vomiting and diarrhea last? Is it constant? Or does it come and go? How many times in 24 hrs. have you had to vomit or go to the bathroom? C: what order symptoms have you noticed, other than vomiting, diarrhea? (Low-grade fever, Tachycardia) A: Does anything make the diarrhea/vomiting worse? Movement? Does it hurt to walk? Jumping up and down on right foot? Is there fatigue? R: Does anything make the diarrhea and vomiting better? Rest? Position changes? T: What have you used? (Sprite, apple juice, and popsicles) Have the (Pepto-Bismol/ Tylenol) helped you feel better? S: Are you able to function normally? Lily: fever, When did the fever start? How high is the fever? (100-101degrees) Does the fever come and go? What symptoms have you noticed with the fever? What time of the day is the fever worse? (In the afternoons) What makes the fever better or does it relieve at certain time of the day? What medication or treatment have you used? (Tylenol- acetaminophen 2-3times) Was it effective? Lily: Abdominal Pain, headache and myalgia When did your abdominal pain start? (This morning) Where is the abdominal pain, (lower abdominal pain) does it move or radiates to any other part of your body? (Unknown). How long does the pain last? Is it constant? Describe your pain.5 on a 1-10 scale, progressing Besides the abdominal pain what other symptoms do you have? Vomiting, diarrhea, Fever, Myalgia Headaches? Does anything make the pain worse? Movement? Does it hurt to walk? Jumping up and down on right foot? Does anything make the pain better? Rest? Position changes? What have you used to alleviate the abdominal pain? Has the Pepto-Bismol or Tylenol helped? How severe is the pain on a scale of 1-10 (5/10), are you able to function normally in your daily activities? School? PMH: Includes being a full-term vaginal delivery weighing 8 lbs. She experienced a right radial fracture at age 5 and tonsillectomy and adenoidectomy at age 7. Allergies: None Medications: None Social History: Sophomore in school, denies being sexually active Lily: Constitutional: Do you currently have fever or chills? Does your skin feel cool or clammy to touch? Eyes: Do you have headaches? Mouth: Does your mouth feel dry? Do you feel thirsty? Respiratory: Do you feel short of breath? Any changes in your breathing pattern? Cardiovascular: Do you have heart palpitations? Does his heartbeat seem fast? GI: How many episodes of diarrhea have you had in the last 24hrs? What does your stool look like? Normal stool? Is it all loose stool? What color is it? Does it have a strange odor? Have you noticed any blood in his stool, mucous? Do you have abdominal cramping? Describe your abdominal pain. How many times have you vomited in the last 24hrs? Is it liquid or food? What color is the vomitus (Bile or green)? Have you noticed any blood? GU: Are you having frequent urination? How much have you had to drink in the last 24hrs? Do you have to wake up frequently in the middle of the night to urinate? Have you been treated for UTI or STIs in the past? Neuro: Are you able to function normally in your daily activities? Are you feeling fatigued, sleeping more? Irritable? Any headaches, dizziness? Reproduction: When was your last menstruation? How long does it last? How long did it last? Was your period normal? Do you get abdominal cramps with your menstruation? Are you sexually active? Have had a history of STI in the past? How many sexual partners do you have? Reference Carson, R. A., Mudd, S. S., & Madati, P. J. (2016). Clinical practice guideline for the treatment of pediatric acute gastroenteritis in the outpatient setting. Journal of Pediatric Health Care. doi:10.1016/j.pedhc.2016.04.012 Colson, S., & Hoffenberg, E. J. (2011). Acute diarrhea. Berman’s Pediatric Decision Making, 220–225. doi:10.1016/b978-0-323-05405-8.00061-9 Coplen, D. E. (2012). Urinary Tract Infection: Clinical practice guideline for the diagnosis and management of the Initial UTI in febrile infants and children 2 to 24months. Yearbook of Urology, 2012, 236–237. doi:10.1016/j.yuro.2012.05.012 Davis, A. (2012). Drug metabolism and pharmacokinetics quick guide. By Siamak C. Khojasteh, Harvey Wong and Cornelis E. C. A. Hop. ChemMedChem, 7(4), 741– 742. doi:10.1002/cmdc.201200027 Damle, L. F., & Gomez-Lobo, V. (2011). Pelvic pain in adolescents. Journal of Pediatric and Adolescent Gynecology, 24(3), 172–175. doi:10.1016/j.jpag.2011.02.002 Dunn, J. C. Y. (2012). Appendicitis. Pediatric Surgery, 1255–1263. doi:10.1016/b978-0- 323-07255-7.00100-8 Dennehy, P. H. (2011). Viral gastroenteritis in children. The Pediatric Infectious Disease Journal, 30(1), 63–64. doi:10.1097/inf.0b013e3182059102 Lobo, R. A. (2013). Ectopic pregnancy. Comprehensive Gynecology, 361–381. doi:10.1016/b978-0-323-06986-1.00017-2 McGee, S. (2012). Hypovolemia. Evidence-Based Physical Diagnosis, 76–77. doi:10.1016/b978-1-4377-2207-9.00010-0 Marsden, J. (2014). Mosby’s manual of diagnostic and laboratory tests Pagana Kathleen and Pagana Timothy Mosby’s manual of diagnostic and laboratory tests. Elsevier. Emergency Nurse, 22(4), 13–13. doi:10.7748/en.22.4.13.s14 Shah, I. (2014). Fever with rash. Pediatric Oncall, 11(3). doi:10.7199/ped.oncall.2014.52 Smith, M. P., Katz, D. S., Lalani, T., Carucci, L. R., Cash, B. D., Kim, D. H., … Rosen, M. P. (2015). ACR Appropriateness Criteria® Right Lower Quadrant Pain— Suspected Appendicitis. Ultrasound Quarterly, 31(2), 85–91. doi:10.1097/ruq.0000000000000118 Sultan, C., Gaspari, L., & Paris, F. (2012). Adolescent dysmenorrhea. Endocrine Development, 171–180. doi:10.1159/000331775 Sulu, B. (2012). Demographic and epidemiologic features of acute appendicitis. Appendicitis - A collection of essays from around the world. doi:10.5772/26184 Tham, T. C. K. (2016). Approach to acute abdominal pain. Tham Gastrointestinal Emergencies, 19–24. doi:10.1002/9781118662915.ch4 [Show More]

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