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Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

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Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

You will complete a Comprehensive SOAP note on the approved Pediatric SOAP Note template based on the findings of the iHuman case – then major research and discussion of the disease process are presented.
This case study should be a summative evaluation supported by a minimum of 5 evidence-based articles.
Evaluation of the case study should be no more than 3-4 substantive paragraphs. A minimum of five evidence-based sources (in addition to your text) should be used for your case study.
Course texts will not count as a scholarly source; if using data from websites you must go back to the literature source for the information-no secondary sources are allowed, ie, Medscape, UptoDate, etc. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
This week, complete the iHuman case titled ”Tommy Acker V3”.

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STUDENT NAME: DATE OF ASSIGNMENT:
Patient Initials: Tommy Acker Date of Encounter:

 

Sex: Male Age/DOB/Place of Birth: 26 months old

2/5/2017

SUBJECTIVE

Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

Historian: Mother

Present Concerns/CC: “Stomach ache” (abdominal pain)

Child Profile: Listless and ill appearing 26-month-old, male with a history of Downs’s syndrome and …. The mother states … as other children. She states that he is clumsy. He is always tripping, falling, or bumping into things as if he does not see that it is there. None of his … in him requiring medical attention. She states that he is normally … and does not require much else. He does not go to day care and lives at home with his two siblings and mother. His mother works and their neighbors or mother’s boyfriend babysit the children. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
HPI:

Onset: xx days ago

Location/Radiation: xxx pain

Duration: xxx over 2 days

Character: xxx

Aggravating factors: xxx

Relieving Factors: none

Timing: constant

Severity: severe

Tommy, a 26-month-old male with Down syndrome, was brought into the ED by his mother who reports he has been “complaining” of… days, had emesis x 1, is lethargic, sweati…is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template… tenderness. A reducible 2.0-cm umbilical hernia is present.

 

Medications: None currently.
PMH: Normal pregnancy and no complications noted at birth.

 

Allergies: None

Medication Intolerances:  None

Chronic Illnesses/Major traumas: Atrioventricular septal defect, tra….

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… thus, meeting more than two criteria for SIRS.

3.       Child Abuse: Act of Commission (T74.12XA): According to the Centers for Disease Control (CDC), physical, … and neglect (CDC, 2019). Neglect is defined as the failure to meet a child’s basic physical and emotional needs, including food, shelter, clothing, education, and access to medical care (CDC, 2019). Physical abuse is intentionally using physical force that may result in injury, such as, hitting, kicking, burning, or shaking of a child (CDC, 2019). Emotional abuse refers to the behaviors that harm a child’s self-worth or emotional well-being, such as shaming, rejection, or withholding love or affection (CDC, 2019). Abuse can come from …factors. In the situation with T.A., the mother was neglecting her children to be able to provide basic needs for them, while depriving them of education and exposing them to physical abuse from her boyfriend. Tommy’s injuries also do not match up to the stories his mother is reporting, and she seemed to take some time to bring him in to be evaluated and became defensive when possible questions that may point toward abuse were asked. Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

4.       Volvulus (K56.2): Volvulus can vary in presentation from vague, recurrent gastrointestinal discomfort to sudden onset of an acute abdomen with associated shock symptoms (Saxena, 2017). It may present in any age group and is not associated with traumatic injury. More often it occurs as a result of a congenital malrotation of the midgut (Saxena, 2017).

PLAN including education
Initial resuscitation and stabilization protocol:

1.       Assess airway, circulation and breathing. Provide oxygen for hypoxia.

2.       Place on …, continuous pulse oximetry, and monitor vital signs.

3.       Place two …. as they are needed.

4.       Complete Primary (airway, breathing, circulation, disability, and exposure) and secondary (head-toe exam) surveys (Kaplan, 2018). Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

T.A. is a child that is critically-ill. He will require further testing such as a … with contrast and an emergent surgical consult. He will also be admitted to the intensive care unit for further management. It is important to contact child protective services, police, and social-work personnel as needed.

 

 

NSG 6435 Week 7 W7 Assignment 1

Assignment 1: Comprehensive Case Study

General Guidelines for Comprehensive Case Study – Week 7 Assignment 1

Your case study should not be just a SOAP note of a patient encounter—it should be a comprehensive evaluation of an iHuman patient case.

You will complete a Comprehensive SOAP note on the approved Pediatric SOAP Note template based on the findings of the iHuman case – then major research and discussion of the disease process are presented.

This case study should be a summative evaluation supported by a minimum of 5 evidence-based articles.

Evaluation of the case study should be no more than 3-4 substantive paragraphs.A minimum of five evidence-based sources (in addition to your text) should be used for your case study.

Course texts will not count as a scholarly source; if using data from websites you must go back to the literature source for the information-no secondary sources are allowed, ie, Medscape, UptoDate, etc.

This week, complete the iHuman case titled “Tommy Acker, Child Abuse”.Click here for information on how to access and navigate Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

Name your SOAP note document SU_NSG6435_W7_A1_lastname_firstinitial.doc

i-Human

i-Human is an interactive cloud based system that provides comprehensive learning that

integrates clinical experience.The i-Human system helps students develop patient assessment

and diagnostic reasoning skills at various levels of education.Students will receive online

guidance, feedback, and coaching during the learning process.

Student Login Instructions for Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

Logging in to i-Human:

Log on at:

http://toolmanagement.next.ecollege.com/tools/thirdparty/blti.ed?launch=LS:iHuman:Patients

Next Steps:

1) If you were unable to attend a Student Orientation Webinar, please watch this introduction

video: https://vimeo.com/185046053/228aea3fc9

2) Additional tutorial videos can be found on the i-Human home screen under the title “Player

Screencast Tutorials”

3) After attending the webinar or viewing the tutorial you are ready for your first practice

case.

4) The i-Human Student Support Center (link on the home screen under the videos) is a

resource for our most frequently asked questions.The Student Manual is also located here.

5) If you are having any issues that are not answered through the webinars, videos or support

center, you can email: support@i-human.com Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

 

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

STUDENT NAME:

Patient Initials:

 

Sex:

 

SUBJECTIVE

Historian:

Present Concerns/CC:

DATE OF ASSIGNMENT:

Date of Encounter:

 

Age/DOB/Place of Birth:

 

Reason given by the patient for seeking medical care “in quotes”

Child Profile:  (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

Sports/physical activity; Developmental Hx)

 

HPI: (must include all components – OLD CARTS)

 

Medications: (List with reason for meds)

 

PMH:

Allergies:

 

Medication Intolerances:

 

Chronic Il nesses/Major traumas:

 

Hospitalizations/Surgeries:

 

Immunizations: Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

 

1 | P E D I A T R I C   S O A P   N O T E

 

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

 

Family History  (please identify al  immediate family)

 

 

Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

and marijuana.  Safety status)

 

Review of Systems (ROS)

 

General

 

Skin

 

Eyes

 

Ears

 

Nose/Mouth/Throat

 

Breast

 

Heme/Lymph/Endo

 

2 | P E D I A T R I C   S O A P   N O T E

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Genitourinary/Gynecological

 

Musculoskeletal

 

Neurological

 

Psychiatric

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

OBJECTIVE  (plot height/weight/head circumference along with noting percentiles)

Attach growth chart

 

Weight

 

Height

Temp

 

Pulse

BP

 

Resp

 

 

OBJECTIVE (Physical Examination)

 

General Appearance and parentchild interaction

 

Skin

 

HEENT

 

Cardiovascular

 

Respiratory

 

Gastrointestinal

 

Breast

 

Genitourinary

 

Musculoskeletal

 

3 | P E D I A T R I C   S O A P   N O T E

 

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

 

Neurological

 

Psychiatric

 

In-house Lab Tests – document tests (results or pending)

 

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

 

ASSESSMENT (Diagnosis – 3 Differentials and Primary)

     Include at least three differential diagnoses with ICD-10 codes.  (Includes Primary dx and 2

differentials) Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.

     Document Evidence based Rationale for ROS and each differential with pertinent

positives and negatives

     Primary diagnosis

     Is #1 on list of differentials

     Evidence for primary diagnosis should be supported in the Subjective and Objective

exams.

1)

 

2)

 

3)

 

4 | P E D I A T R I C   S O A P   N O T E

 

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

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

Fol ow-up appointment with detailed plan of  f/u

 

*ALL references must be Evidence Based (EB)

 

5 | P E D I A T R I C   S O A P   N O T E

Pediatric_Fillable_SOAP_Note_Template–

growth_chart

Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template

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