Soap Note 5 on Nausea

Sample Answer

Soap Note on Nausea
Name D.M Date 18TH Sep 2023 Time 1200H
Age 10 years old Sex Male
SUBJECTIVE
CC Nausea

HPI The patient is a 10-year-old male experiencing acute nausea and intermittent vomiting. He vomited twice yesterday and three times today with no discernible pattern. The patient’s mother reported that he had experienced postprandial gastrointestinal discomfort.

The individual presents with moderate watery diarrhea accompanied by blood and mucous and periodic headaches, pains all over, and stomach pain. Upon his recent return from soccer camp, he had been in contact with other children exhibiting similar symptoms.

Onset 2 days ago

• Location gastrointestinal
  
• Duration twice yesterday and three times today.
  
• Characteristics postprandial gastrointestinal discomfort
  
• Alleviating & Aggravating factors
  
• Timing after meals
  
• Severity 5/10
  
• Medications None

PMH The patient reports no history of any medical condition. All immunizations are up to date.

• Allergies None
  
• Medication Intolerances None
  
• Chronic Illnesses/Major traumas None
  
• Hospitalizations/Surgeries None
  

Family History Mother is suffering from migraines. The father has a history of diabetes and hypertension. Social History The patient lives with her parents, three younger sisters, and other family members. The patient and her mother consider their house a private and safe place.

The patient lends a hand around the home. The patient reports being academically successful and earning good marks in the fifth grade. The patient claims to enjoy skating and a busy social life.

ROS

• General: According to the patient’s mother, while the patient typically has excellent health, he is now not feeling well and does not seem to be himself.
• Cardiovascular: Denies having any orthopnea, palpitations, edema, or chest pain.
• Skin: denies having any recent rashes, itching, dryness, blisters, texture or color changes, or moles. Changes to the skin, hair, or nails. Respiratory denies having a cold, the flu, pneumonia, hemoptysis, or a cough
• Eyes: denies any changes in eyesight
• Gastrointestinal: Reports feeling ill in his stomach, with dry hives and nausea. Today, States had 3–4 episodes of crimson diarrhea that looked mucusy.
• Ears: Denies feeling any ear pain, hearing loss, ringing, or discharge.
• Genitourinary/Gynecological: Denies the existence of regular burning, urgency, and changes in the color of the urine.
• Nose/Mouth/Throat: Denies having swollen glands, bleeding gums, dental discomfort, sores, lesions, sore throat, or a change in taste. Has healthy teeth.
• Musculoskeletal: Denies osteoporosis, joint pain, stiffness, or back discomfort.
• Breast: denies breast discomfort or bumps Neurological
• Gcstrjoetastoecn: Denies having epileptic fits, syncope, momentary paralysis, weakness, numbness or tingling, or blackouts
• Heme/Lymph/Endo: Increased bruising, hypersensitivity to blood transfusions, nocturnal sweats, enlarged glands, increased hunger and thirst, and sensitivity to cold or heat.
• Psychiatric: Denies experiencing sadness, anxiety, sleep issues, or suicidal thoughts or attempts

OBJECTIVE

• Weight 70lbs BMI 16.3 (49th percentile) Temp 97.8 F BP 110/70 mmHg
• Height 139.7cm Pulse 88bpm Resp 20 cpm

General Appearance: The patient is attentive and focused, well-groomed and clothed, and exhausted.

• Skin
  Race-appropriate skin tone and reduced skin turgor.

HEENT
The face is symmetrical, has characteristics suitable for the race, no weakness or sagging, no involuntary movements, no tumors, lesions, or soreness, and the head is normocephalic. White sclera, pink conjunctiva, intact extraocular motions on both sides and PERRLA are all present in symmetrical eyes.

The patient’s eyesight is 20/20 on the Snellen chart for both their right and left eyes. The ear canal is pink and patent. Symmetrical, midline septum, patent nares, pink and moist, no swelling apparent. The tongue is at the midline and moves freely; the oral mucosa is pink and wet; there are no anomalies in the gums or teeth, no lesions, no masses, and proper oral hygiene. The bilateral tonsils are 1+ in size.

Cardiovascular
Constant beat; absence of audible pulsation, heaves, or rises; 5th intercostal margin left mid-clavicular line, apical impulse, S1 S2 present, no further heart sounds; no murmur, no thrills; bilaterally, carotid arteries that are 2+ and equal

Respiratory
a uniform chest wall. Regular and easy respiration; both sides of the lungs are audibly transparent.

Gastrointestinal
Flat, symmetrical abdomen, skin that is the right color for the patient’s ethnicity, no rashes, no apparent peristaltic movement or pulsations, hyperactive bowel noises in all four quadrants, minor abdominal soreness, no rebound tenderness, and tympanic in all four quadrants.

Breast

• There are no lumps.

Genitourinary

• No urethral discharge. Testicles are palpable.

Musculoskeletal

• Exhibits full range of motion in both upper and lower extremities

Neurological

• Stable balance and normal gait.

Psychiatric

• focused and awake. No hallucination or delusion.

Lab Tests

• Urinalysis and stool culture were ordered to determine the cause of the patient’s nausea and diarrhea.

Special Tests None

Diagnosis

Differential Diagnoses

Bacterial gastroenteritis The patient presents with symptoms including acute vomiting, intermittent stomach discomfort, diarrhea, and a low-grade temperature are symptoms of acute gastroenteritis (Hartman et al., 2019).

Viral gastroenteritis The condition is characterized by diarrhea, vomiting, fever, stomach discomfort, anorexia, headache, malaise, moderate dehydration, and moderate abdominal soreness (Florez et al., 2020). The patient provided the majority of the reported information.

Food poisoning Food poisoning is characterized by the abrupt onset of symptoms such as nausea, vomiting, diarrhea, headache, malaise, and intermittent abdominal pain (Zeaki et al., 2019). Primary Diagnosis gastroenteritis- the causative organism will be determined upon collection of the lab test results.

Plan/Therapeutics

Plan

• A metabolic profile and CBC. White blood cell counts increasing would be indicative of a bacterial process. Left shift and an abnormally high white blood cell count are often signs of shigella infection. However, bacterial gastroenteritis may produce similar results (Leader et al., 2020). An infection with a parasite would be suggested by eosinophilia.
• Acetaminophen and ibuprofen PRN for fever (Wollmer et al., 2022)
• Inform the patient on how to monitor their symptoms and constantly drink plenty of water.
• Get enough sleep and eat well to aid in a speedy recovery.

Evaluation of patient encounter

Follow-up If symptoms worsen after one week of returning to care (RTC), further evaluation and intervention may be necessary.

References

• Florez, I. D., Niño-Serna, L. F., & Beltrán-Arroyave, C. P. (2020). Acute Infectious Diarrhea and Gastroenteritis in Children. Current Infectious Disease Reports, 22(2). https //doi.org/10.1007/s11908-020-0713-6
• Hartman, S., Brown, E., Loomis, E., & Russell, H. A. (2019). Gastroenteritis in Children. American Family Physician, 99(3), 159–165. https //www.aafp.org/pubs/afp/issues/2019/0201/p159.html/
• Leader, G., O’Reilly, M., Gilroy, S. P., Chen, J. L., Ferrari, C., & Mannion, A. (2020). Comorbid Feeding and Gastrointestinal Symptoms, Challenging Behavior, Sensory Issues, Adaptive Functioning, and Quality of Life in Children and Adolescents with Autism Spectrum Disorder. Developmental Neurorehabilitation, 24(1), 35–44. https //doi.org/10.1080/17518423.2020.1770354
• Wollmer, E., Ungell, A.-L., Nicolas, J.-M., & Klein, S. (2022). Review of pediatric gastrointestinal physiology relevant to the absorption of orally administered medicines. Advanced Drug Delivery Reviews, 181, 114084. https //doi.org/10.1016/j.addr.2021.114084
• Zeaki, N., Johler, S., Skandamis, P. N., & Schelin, J. (2019). The Role of Regulatory Mechanisms and Environmental Parameters in Staphylococcal Food Poisoning and Resulting Challenges to Risk Assessment. Frontiers in Microbiology, 10. https //doi.org/10.3389/fmicb.2019.01307