Assignment: SOAP Note Pediatric Issue ESSAY

Assignment: SOAP Note Pediatric Issue

Assignment: SOAP Note Pediatric Issue

Name: Chris West Pt. Encounter Number: 2098/19
Date: 3-08-2019 Age: 2 years Sex: Male
SUBJECTIVE
CC:
The child mother reports,” My son has a strange cough that sounds like he is barking which worsens at night and has a hoarse voice. He is also experiencing difficulty in breathing.”
HPI:
The mother reports that the cough and hoarse voice started two days ago and had an abrupt onset. The cough has a barking characteristic and worsens at night. The cough is partially relieved by the intake of warm fluids. The mother also reports that the child has been having a hoarse cry, high body temperature, and production of light mucus. The child also has difficulty in swallowing and is unable to feed. There has been no history of swallowing a foreign material. She had administered the child with OTC paracetamol syrup to lower the body temperature and lower symptom, which was successful for some time, but the symptoms later recurred. Mother reports that the child’s immunization schedule is up to date.
Medications:
Paracetamol syrup to lower body temperature and relieve cough symptom.

PMH
Allergies:
No known food, environment or drug allergies.
Medication Intolerances:
No intolerance to drugs.
Chronic Illnesses/Major traumas
No history of chronic illnesses. No history of birth injuries or major traumas.
Hospitalizations/Surgeries

No history of hospitalization or surgery.
Family History
Chris is the 2nd born in a family of 2. Mother reports that the first born child has asthma. Mother and father have no history of chronic illnesses. Maternal grandmother has DM.

Social History
Lives with his parents in an urban town and has not yet enrolled to kindergarten. Mother reports that the child interacts well with family members and children his age.

ROS
General
Fever, lethargic, and inability to feed.
Cardiovascular
Reports difficulty in breathing. Denies bluish discoloration of lips and nails and edema.

Skin
Denies skin discoloration, bleeding, rashes or lesions. Respiratory
Reports a barking cough, difficulty in breathing. Denies hemoptysis, and wheezing. No history of TB or pneumonia.
Eyes
Corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Unable to feed.
Denies vomiting, diarrhea, constipation, or black tarry stools.

Ears
Denies hearing loss and ear discharge.
Genitourinary/Gynecological
Denies urinary urgency, frequency, change in urine color and discomfort when passing urine.

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Nose/Mouth/Throat
Reports mucous discharge.
Denies facial swelling, nose bleeding.

Difficulty in swallowing and hoarse voice. Musculoskeletal
Denies difficulty in walking, maintaining balance and muscle swelling. No history of fracture.
Breast
Denies breast swelling. Neurological
Reports lethargy
Denies history of seizures, paralysis, or fainting.
Heme/Lymph/Endo
No history of blood transfusion. Denies night sweats, acute thirst, increased hunger and heat or cold intolerance. Psychiatric
Denies history of anxiety disorder or sleeping disorders.
OBJECTIVE
Weight 29 pounds
BMI 18.2 Temp 100.94 F BP NA
Height 2’8 Pulse 128 Resp 40
General Appearance
Child in moderate respiratory distress, lethargic and agitated.
Skin
Skin is fair, clean, warm, dry, and intact. No rashes, bruises or lesions noted.
Skin pinch goes back slowly.
HEENT
Head is symmetrical, normocephalic, and atraumatic. No lesions noted. Hair is blonde and evenly distributed. Eyes: Non-inflamed sclera and conjunctiva; PERRLA. EOMs intact. Ears: Ear canals patent, ear wax present, tympanic membrane intact. Mastoid bone non-inflamed. Nose: Clear mucous discharge present. Nasal mucosa pink; nasal septum well-aligned.
Neck: Full ROM; non-palpable cervical lymph nodes and occipital nodes. Thyroid gland normal.
Mouth: Pink and moist oral mucosa. Has 16 teeth with no cavities. Tonsillar gland and pharynx are non-erythematous.

Cardiovascular
No jugular vein distension and edema noted. S1, S2 present with regular rate and rhythm. On auscultation, heart rubs, bruits and murmurs absent. Capillary refill time 2 seconds. No central or peripheral cyanosis present.
Respiratory
Chest wall retractions during inspiration. Breathing is labored. Tachypnea. On auscultation, stridor is present during inspiration. Diminished breath sounds and crackles perceived. Wheezing absent.
Gastrointestinal
Abdomen is smooth and flat. Bowel sounds present and active in all abdominal quadrants. No tenderness on palpation, no hepatomegaly or splenomegaly.
Breast
Breasts are non-tender and have no lumps.
Genitourinary
Both testes present and palpable. No urethral discharge noted.
Non-distended bladder. Perianal sore absent, no anal fissures or hemorrhoids noted. Rectal bleeding absent.

Musculoskeletal
Poor muscle tone. Bones and spine well-aligned. Normal gait, posture and stable balance.
Neurological
Speech is not fully developed. Speaks hesitantly. Stable balance, normal gait and posture.
Psychiatric
Lethargic child. Hyperactivity, stranger anxiety and social withdrawal absent. Has a social smile.
Lab Tests
WBCs Count- 4800/ mm3
Special Tests
Pulse oximetry- 92%

Diagnosis
Differential Diagnosis
Bacterial Tracheitis: A rare cause of upper airway obstruction characterized by inflammation of the larynx, trachea, and bronchi. Patients with bacterial tracheitis present with a barking cough, hoarseness, sore throat, fever, and a high WBC count (Tristram, 2019).Respiratory findings include nasal flaring, tachypnea, retractions, inspiratory stridor, and respiratory distress (Midulla, Guidi & Barbato, 2018). Bacterial tracheitis is a possible diagnosis based on the patient’s symptoms of a barking cough, fever, hoarseness, barking cough, and difficulty in swallowing. It is also likely as per physical findings of tachypnea, retractions stridor on inspiration and respiratory distress. However, there is a negative finding of a normal EBCs count.
Epiglottis: This is an inflammation of structure located above the glottis and is caused by a bacterial infection. Acute inflammation of the epiglottis results in swelling and obstruction of the upper airway (Tristram, 2019). Symptoms often have an abrupt onset and are severe. The typical triad of epiglottis includes drooling, distress, and dysphagia. Other symptoms include temperatures of above 104 F, stridor, refusal to eat, sore throat, hoarse voice, and anxiety (Midulla, Guidi & Barbato, 2018). Cough is a less frequent symptom. Epiglottis is a probable diagnosis as per findings of difficulty in swallowing, respiratory distress, hoarse voice, and inability to eat. However, there are negative findings of drooling, very high temperatures, and cough.
Whooping cough: This is a respiratory tract infection that manifests with paroxysmal cough and caused by Bordetella pertussis. It occurs in three phases, referred to catarrhal, paroxysmal, and convalescent (Gopal, Barber & Toeg, 2019). Catarrhal phase is characterized by nasal congestion, sneezing, low-grade fever, rhinorrhea, and tearing. The second phase manifests with paroxysms of severe coughing that last for several minutes, accompanied by a loud whoop and post-coughing vomiting (Gopal, Barber & Toeg, 2019). The convalescent stage has a chronic cough which lasts for weeks. Whooping cough is a likely diagnosis based on positive symptoms of cough and rhinorrhea. However, the characteristic of a paroxysmal whoop cough rules it out as a final diagnosis.
Final Diagnosis
Croup. Croup is vital respiratory condition common in pediatrics caused by Parainfluenza viruses. It primarily affects the larynx and trachea but may also involve the bronchi (Midulla, Guidi & Barbato, 2018). It is characterized by hoarseness, barking cough, stridor on inspiration, and significant respiratory distress. Croup begins with mild symptoms of rhinorrhea, cough, low-grade fever, and a sore throat (Gates, Johnson & Klassen, 2019). After 1-2 days, there is a sudden onset of a barking cough, hoarseness, inspiratory stress, and respiratory distress (Ortiz-Alvarez, 2017). The symptoms worsen at night and mostly resolve within 3-7 days but can persist for two weeks. On physical exam, children with croup are lethargic, and agitated and have tachycardia, tachypnea, diminished breath sounds, and loss of muscle tone (Gates, Johnson & Klassen, 2019). Patients unable to feed manifest with signs of dehydration and cyanosis occurs in very severe cases. Croup is the most likely diagnosis based on the child’s symptoms of a barking cough, difficulty in breathing, hoarseness, rhinorrhea, difficulty in feeding, lethargy, and agitation. Besides, positive physical exam findings of stridor, faint breath sounds, tachypnea, tachycardia, high body temperature, poor muscle tone, and respiratory distress make it a final diagnosis.
Plan
Further diagnostic tests: Neck X-ray within 8 hours; to rule out disorders that present with stridor and to help confirm the diagnosis.
Medication:
i. Dexamethasone 10 mg IM STAT; to reduce laryngeal mucosal edema (Gates, Johnson & Klassen, 2019).
ii. Nebulized Epinephrine 0.5mL BD, diluted with 3 mL normal saline over 15 minutes; to decrease airway edema (Ortiz-Alvarez, 2017).
iii. Ibuprofen suspension 100 mg PO TDS; to lower the fever.
Non-pharmacological measures: Propping the patient to ensure airway patency and allow for chest expansion.
Oxygen therapy to promote and maintain adequate tissue perfusion (Ortiz-Alvarez, 2017).
Intravenous therapy with normal saline to rehydrate body tissues.
Health education: The mother will be advised to keep the child away from smoke as it triggers exacerbations.
She will be recommended to offer the child warm light fluids to loosen mucus.
Expose the child and offer fluids when having a fever.
Follow-up: A follow-up visit will be scheduled two weeks after discharge for evaluation of progress and identification of complications.
The mother will be advised to bring the child for immediate emergency attention if the symptoms worsen such as severe respiratory distress, high fevers, and inability to feed.

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