Nursing

profileMR.Sharper

 

Below is the template you are to follow when developing your management plan. Also, always be sure to complete the EMR on the case. Use this template with each case. It is not a SOAP format as that is not required. Points will be deducted for not utilizing the template.

THIS SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each bullet point on a word document and cut and paste your responses to the management section!

 

  •  Primary Diagnosis and ICD-10 code: Also include any procedural codes.
  • 3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.
  • Additional laboratory and diagnostic tests: It may be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier. 
  • Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending it to the hospital, what orders would you write for a direct admit? 
  • Therapeutic modalities: pharmacological and nonpharmacological management. 
  • Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.
  • Patient education: Explanations and advice given to patient and family members. 
  • Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.
  • References (minimum of 3, timely, that prove this plan follows the current standard of care

 

 

 

 

 

 

 

Pediatric SOAP Note

Name: P. L

Date: 03/09/2018

Sex: Male

Age/DOB/Place of Birth: 16 y.o/03/01/2001/Cuba

SUBJECTIVE

Historian: Mother and patient

Present Concerns/CC: “I’ve been having horrible headaches on and off for the last 2 weeks”

Child Profile:

Patient is a high school student with no significant past medical history. He is enrolled in a dual program where he is taking college classes in advance. Described by his mother as an A+ student. He does participate in sports at school being part of the baseball league. Patient goes to school during the day and spends most of his free time studying. He eats a balanced diet including meat, vegetables, and salads. Patient drinks water throughout the day and does not like soda beverages. Denies drinking energetic drinks. He uses seatbelt at all times while in a car.

HPI:

Otherwise healthy 16 y/o male seen in the office for complaints of daily headache for 2 weeks. Pain is described as dull and pounding and intermittent. Pain is mainly located in the back of the head but at times radiates to the top and to the sides. Patient can’t say if there are specific triggers for the pain because he experiences it at any time. Pain is alleviated by rest and in other instances he has taken Excedrin Extra Strength with little relief. Denies photophobia, blurred vision, or diplopia. Patient admits to some pressure with the studies as he is trying to get a full scholarship for university.

Med

Medications:

Benadryl pen for sleep

Acetaminophen or Advil pen for headache

Excedrin prn

PMHX:

Allergies: NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up to date

Family History

Mother and father alive. Mother has history of GERD and father suffers from HTN. Paternal grandparents are deceased. Both of old age. Maternal grandfather and maternal grandmother are alive, and they only suffer from GERD and OA.

Social History

Patient is only child and lives with his parents. He is currently on high school. He is enrolled in a dual program where he is taking college classes in advance. He spends most of his time studying. He has applied to various universities and expects to obtain full scholarship. Mother denies guns at home or exposure to second hand smoking. Patient does not work because his school requires him to spend a great amount of time to it. Both parents are very supportive of patient. Patient denies being sexually active and denies having a girlfriend. He has a group of close friends.

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