Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template
Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template
Pediatric SOAP Note – Tommy Acker
Student Name: Date of Assignment:
Patient Initials: Tommy Acker Date of Encounter:
Sex: Male Age/DOB/Place of Birth: 26 months old
SUBJECTIVE
Historian: Mother Present Concerns/CC: “Stomach ache” (abdominal pain)
Child Profile: Listless and ill-appearing 26-month-old male with a history of Down syndrome. The mother reports Tommy as clumsy, frequently tripping or falling. He lives at home with two siblings, taken care of by neighbors or the mother’s boyfriend. Tommy doesn’t attend daycare.
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 with Down syndrome, presented to the ED with complaints of abdominal pain persisting for several days. Notably, he exhibited lethargy, vomiting once, and sweating. Physical examination revealed significant epigastric bruising, inconsistent with a typical fall. Tommy’s abdomen is distended and firm, with tenderness. A reducible 2.0-cm umbilical hernia is noted.
Medications: None currently. PMH: Normal pregnancy and uncomplicated birth.
Allergies: None Medication Intolerances: None Chronic Illnesses/Major Traumas: Atrioventricular septal defect, traumatic event history.
ASSESSMENT
Sepsis (R65.10): Elevated heart rate, temperature, and abnormal WBC count meet criteria for Systemic Inflammatory Response Syndrome (SIRS). Tommy is at risk for sepsis, and immediate intervention is crucial.
Child Abuse: Act of Commission (T74.12XA): Indicators of neglect and physical abuse are evident. The injuries do not align with the reported history, and delay in seeking medical attention is concerning. The mother may be neglecting the children, exposing them to abuse from her boyfriend.
Volvulus (K56.2): Volvulus can show up in different ways, from recurring stomach discomfort to a sudden, intense belly pain with signs of shock (Saxena, 2017). It can happen at any age and isn’t usually linked to injuries. Often, it results from a congenital issue where the midgut twists (Saxena, 2017).
PLAN including education Initial resuscitation and stabilization protocol:
Check the airway, circulation, and breathing. Give oxygen if needed.
Use monitors for oxygen levels and vital signs.
Place tubes as necessary.
Go through primary (airway, breathing, circulation, disability, and exposure) and secondary (head-to-toe exam) surveys (Kaplan, 2018). Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template.
T.A. is a very sick child. He needs more tests like a … with contrast and an urgent surgical consult. He should be admitted to the intensive care unit for further care. It’s crucial to involve child protective services, the police, and social-work personnel as required.
General Guidelines for Comprehensive Case Study – Week 7 Assignment 1
Your case study must go beyond just a SOAP note. It should be a thorough review of an iHuman patient case, backed by at least 5 evidence-based articles. The evaluation should be concise, around 3-4 paragraphs. Use a minimum of five evidence-based sources, excluding your textbook. Avoid using websites directly; trace the information back to the literature source. This week, work on the iHuman case titled “Tommy Acker, Child Abuse.”
Student Login Instructions for Tommy Acker ihuman case study: Pediatric Fillable Soap Note Template: Access i-Human at:
http://toolmanagement.next.ecollege.com/tools/thirdparty/blti.ed?launch=LS:iHuman:Patients
If you missed the Student Orientation Webinar, watch the introduction video: Introduction Video. Tutorial videos are available under “Player Screencast Tutorials.” For additional help, visit the i-Human Student Support Center or email support@i-human.com.
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 parent–child 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)
Related Services