For this Assignment, you will work with a pediatric patient with gastrointestinal or genitourinary condition

For this Assignment, you will work with a pediatric patient with gastrointestinal or genitourinary condition that you examined during the last 3 weeks, and complete a Focused SOAP Note Template in which you will gather patient information, relevant diagnostic examination."

The structure for admiral of a Focused SOAP Note for a Pediatric patient with a G/I or GU diagnosis is as follows: The following template shall help you in capturing different patient details as well as the necessary diagnostic tests. Always should consider the individuality of the particular client and the diagnosis he/she was given.

 

 Focused SOAP Note Template

 S: Subjective

 Chief Complaint:

 

 The purpose of the patient visit (for example, pain in the stomach, discomfort with the urine, and the like).

 History of Present Illness (HPI):History of Present Illness (HPI):

 

 Additional information on the symptomatology as regards: onset, duration, site, severity and nature of the complaints.

 Any other complaint (e. g. , vomiting, dysuria, fever, etc),

 A treatment or medication that was given before the current episode of treatment.

 Whether there are any recent changes in the diet, lifestyle or any habits regarding the patient.

 Past Medical History (PMH):

 

 Related G/ GU disorders ( e. g. , chronic constipation, recurrent UTI).

 Previous surgeries or hospitalizations.

 Medication History:

 

 Prescriptions and non-prescriptions drugs, and natural products that are taken at the present.

 If there was any shift in the patient’s medication dosage in the last two months.

 Allergies:

 

 Prior medical history including allergic reactions such as to drugs or food products.

 Family History:

 

 A requirement of family medical history with special focus to any gastrointestinal or genitourinary abnormalities.

 Social History:

 

 Diet and fluid intake, bowel and bladder control, suicidal ideation, and other factors that may affect present health.

 Review of Systems (ROS):

 

 Other systems found in other studies that were reviewed (e. g. , changes in weight, alteration in bowel habits, changes in the frequency of urination, or pain).

 O: Objective

 Vital Signs:

 

 This includes temperature, pulse, rate of respiratory movements, blood pressure, and end morning weight.

 Physical Examination:

 

 General Appearance: Well-being of a patient in general (e. g. , well-nourished, upset).

 Abdominal Exam: Inspection, palpation, percussion and auscultation. Signs and symptoms that should be reported include: Tenderness, distention, visible masses and gastric sounds.

 Genitourinary Exam: Examination for any irregularities or symptoms of infection (for instance inflammation, redness, pus).

 Diagnostic Tests:

 

 Laboratory Tests: Tests done on blood samples; complete blood count, comprehensive metabolic panel, urinalysis or other tests which may be stool based.

 Imaging Studies: Any relevant investigations carried out as part of clinical history (e. g. abdominal ultrasound, X – ray).

 Other Diagnostic Exams: Other investigations done in the course of assessment prior to diagnosis, for instance endoscopy or urodynamics.

 A: Assessment

 Diagnosis:

 

 Debugging and differential diagnostic approach which may be based on subjective and objective data.

 Differential diagnoses if applicable.

 Clinical Impression:

 

 Conclusions that have been made together with their relation to the diagnosis.

 P: Plan

 Treatment Plan:

 

 Medications: Certain medications, their quantities and timings.

 Non-Pharmacological Treatments: A treatment for change in diet, alteration in lifestyle or physiotherapy.

 Follow-Up: Possible procedures that the patient should follow up, further appointments and any referrals to other specialists.

 Patient Education:

 

 Teaching given to the patient and or the family (e. g. , how to take the medications, when and what to eat).

 Further details concerning the symptoms and signs to look for.

 Additional Testing:

 

 Whether there is a need for any other test in diagnosing or managing the condition.

 Preventive Measures:

 

 Prevention advice for recurrence or complications.

 Example of a Focused SOAP Note for a Child with Gastrointestinal Problem

 S: Subjective

 

 Chief Complaint: Pain in the stomach and tendency to loose bowel movements.

 HPI: It began two days ago: the patient complains of abdominal pain accompanied by frequent, watery diarrhoea. The pain is cramp-like and in particular in the lower abdomen. Does not present with fever or vomiting. The patient has not been on any change of diet but the patient has recently joined school.

 PMH: None of the patient’s past medical history that may have any bearing on the case presented herein is documented.

 Medication History: None of the present regular medications.

 Allergies: No known allergies.

 Family History: It is also important you know that mother has had Irritable Bowel Syndrome IBS in the past.

 Social History: No fever, no diarrhea, traveling not more than two weeks’ ago, and no contact with sick people.

 ROS: Negates weight loss, altered eating, or defecation containing blood.

 O: Objective

 

 Vital Signs: Temperature 98. Temperature = 6 ℃, pulse = 88 per min, respiratory rate = 18 per min, systolic blood pressure = 105 mm Hg, diastolic blood pressure = 65 mm Hg, weight = 30 kg.

 Physical Examination:

 General Appearance: Well-nourished, alert.

 Abdominal Exam: In the lower abdomen, there is a mild to moderate degree of palpatory tympany; there is no (positive) peritoneal sign, no (positive) hepatic dullness, and normoauscultation is noted for the bowel sounds.

 Genitourinary Exam: No deviations from a normal condition; al! is well.

 Diagnostic Tests:

 Laboratory Tests: CBC reveals raised RMNS and mild anemia, the stool test for rotavirus is positive.

 Imaging Studies: None was done at this time.

 A: Assessment

 

 Diagnosis: Severe diarrhoea due to rotavirus.

 Clinical Impression: Lab findings: Symptoms and presence of virus in the stools are in favor of viral cause.

 P: Plan

 

 Treatment Plan:

 Medications: Rehydration solutions as fluids for issuance to patients.

 Non-Pharmacological Treatments: Make the client to drink a lot of liquid as well as ensure that he/she rests well.

 Follow-Up: More… If not getting better or worsen after 3-5 days reconsider.

 Patient Education: Quizzed parents on likely symptoms of dehydration and the need to hydrate their children. Told on measures to be taken to avoid contracting the diseases particularly on matters concerning hygiene.

 Additional Testing: At this time there are no further tests required.

 Preventive Measures: Suggest rotavirus vaccination especially in children in order to avoid future cases of the same.