Soap Note: 10-Year-Old Male
Encounter date: ___15th June 2024 _
Patient Initials: _J.S. _ Gender: M/F/Transgender _M _ Age: _10 _ Race: _White _ Ethnicity _Non-Hispanic
Reason for Seeking Health Care: _The child's parents report that the child has a persistent cough and breathing challenges.
HPI:_ J. S. is a ten-year-old male whose parents are very concerned about having a cough that has been persistent for the past three weeks and is non-hacking; it worsens at night and wakes him up. This cough is followed by wheezing, and there is noticeable shortness of breath, especially while exercising; this is because he used to be able to play soccer before developing any problems. His mother also says he has had chest pains but no fever. At the same time, he has been sneezing and rubbing his eyes, which might also be allergies. They have not reported any sickness among their close associates recently and did not travel to any part that could bring such diseases. His symptoms have not been improving despite using over-the-counter medication. Considering the patient’s past medical history and the provided symptoms, there is a possibility of an asthma exacerbation caused by allergic triggers –asthma and allergic rhinitis.
Allergies (Drug/Food/Latex/Environmental/Herbal): None
Current perception of Health: Excellent Good, Fair, Poor
Past Medical History
Major/Chronic Illnesses__J.S. was diagnosed with asthma at age 6. He also has allergic rhinitis _
Trauma/Injury _None _
Hospitalizations _J.S. was hospitalized at age seven due to asthma exacerbation _
Past Surgical History_None _
Medications: __J.S. is currently using an albuterol inhaler when necessary, fluticasone nasal spray, and montelukast 5 mg every day _
Family History: _The mother has asthma, the father has hypertension, the siblings have no major illnesses, and the maternal grandfather has type 2 diabetes. _
Social history:
Lives: Single-family House/Condo/ with stairs: _ Single family house with stairs _ Marital Status: _ Parents married_ Employment Status: _Student_ Current/Previous occupation type: _Student _
Exposure to: _Smoke_ The father smokes outside the house _ ETOH _No _Recreational Drug Use: __None _
Sexual orientation: _N/A _ Sexual Activity: _N/A _ Contraception Use: _N/A _
Family Composition: Family/Mother/Father/Alone: _J.S. lives with their mother, father, and the paternal grandmother _
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _Up to date _
Exposures: None
Immunization H.X.: Up to date, including yearly influenza vaccination
Review of Systems:
General: There have not been any new episodes of fever in the last few weeks, any loss of weight, or fatigue on the part of J. S. It is noted that he has a generally satisfactory state of health, except for cough and respiratory problems.
HEENT: J.S. has nasal congestion and itching eyes, but he does not have a throat or earache. There is no headache associated with it or pain in the sinus area.
Neck: J.S. reports that he did not suffer from any neck pain or swollen lymph nodes. There is no palpable enlargement of neck nodes during the assessment of his neck.
Lungs: J.S. has a persistent cough, wheezing, and occasions of breathlessness more often when engaging in games. The symptoms have developed over time and have become worse, particularly at night, causing a cutoff in his sleep.
Cardiovascular: J. S. confirms to be free of chest pain, palpitations, or syncope. He has a regular rate and rhythm on examination.
Breast: Not applicable
G.I.: J.S. does not present with acute abdomen or gastrointestinal upset symptoms such as abdominal pains, nausea, or vomiting. He has no diarrhea, which indicates good gut health, nor does he suffer from constipation.
Male/female genital: Not applicable
GU: J. S. denies having dysuria or gross hematuria. There is no problem with urine frequency, and a normal urination process is observed in the client's case.
Neuro: J.S. dismisses any headaches, dizziness, and, similarly, any history of seizures. The mental status examination shows that he is fully oriented, that the cranial nerve examination is regular, and that he does not exhibit any focal neurological abnormalities.
Musculoskeletal: J.S. has no complaints of muscle pain or joint swelling. He demonstrates no swelling or deformity of the parts; he has normal movement of all limbs without any degree of tenderness.
Activity & Exercise: J.S.'s mobility has been limited by breathing troubles, resulting in less activity and exercise. He has had to cut down on playing games and other physical activities that children enjoy.
Psychosocial: J.S. has no change in his behavior or expression. He is alert and cheerful talking, but his parents are worried because his sleep pattern has changed lately.
Derm: J. S. has no rashes, skin changes, or other skin-related indications. No skin abnormality was noted during the general examination of the skin.
Nutrition: Pupillary reflexes, skin, and appetite are expected, and he eats appropriate food. The quantities consumed and types of food chosen are mostly the same regarding his diet.
Sleep/Rest: J. S. has occasional night-time awakenings because of a cough.
LMP: Not applicable
STI Hx: Not applicable
Physical Exam
BP_110/70 mmHg _TPR_98.60F _ HR: _80 _ RR: _16 _Ht. _4’6” _ Wt. _70lbs_ BMI (percentile) _16 (normal)
General: J. S. is well-built and has good body habitus, and there is no sign of acute respiratory difficulty. The patient is awake and cooperative during the assessment.
HEENT: Head: The head is normocephalic and atraumatic, and no swellings or other abnormalities are visible. Eyes: Tears and conjunctiva are clear; sclerae are free from redness and secretion. Ears: Tympanic membranes are intact and routine, and there is no evidence of infection or the presence of fluid. Nose: Nasal mucosa is turbid and represents a pale pink color, possibly due to allergic rhinitis. Throat: No remarks of erythema, exudates, or infections in the throat for the client.
Neck: It is flexible without any lymphadenopathy, and there is no stiffness when moving the neck. The trachea is midline, and the thyroid gland is not palpable.
Pulmonary: The patient has bilateral wheezing, especially during expiration, and decreased vocal fremitas in the lower lobes.
Cardiovascular: J.S. has an average heart rate and rhythm, with no murmurs, gallops, or rubs. Peripheral pulses are typically and symmetrically defined and include radial, dorsal, posterior tibial, and pedal pulses.
Breast: Not applicable
G.I.: J.S. has no enlargement of the organs, no palpable masses, and the abdomen is soft and non-tender to touch. Ahumeral bowel sounds are audible, and borborygmus is noted.
Male/female genital: There were no apparent lesions or diseases concerning the patient's genital organs.
GU: The external genitalia are intact, and no lesions or discharges have been observed on the patient. A standard urine culture was performed, and there was no evidence of urinary tract infection.
Neuro: J. S. is oriented and has no pathology of the reflexes. The facial, auditory, and vestibulocochlear nerves and the glossopharyngeal, vagus, cranial accessory, hypoglossal, and nerves are preserved.
Musculoskeletal: J.S. can move all the joints without any limitation; there is no abnormality in shape or size, no enlargement of any part of the body, or joint pains. Gait is normal.
Derm: The patient’s skin is without any rash, lesion, or signs of an infection on the body. J.S. has no skin disease, including eczema and other skin diseases that may hinder the effectiveness of the treatment.
Psychosocial: J. S. complies with the examination and keeps his eyes open wide. He looks happy and opens his mouth to speak, although he does not talk much.
Misc.: There are no other findings to report. The rest of the examination is regular.
Significant data: J. S. is a 10-year-old male who has been newly diagnosed with asthma and allergic rhinitis; he has had a 3-week history of continuous, non-homeric cough and worsening at night. Wheezing and shortness of breath are his main complaints, most evident when playing soccer. Further, he complains of chest pains with an interval of one to three months and also has signs of allergic rhinitis, including a runny nose and itchy eyes. Even when he uses over-the-counter cough medicines, there is no improvement, which might be a sign of an Asthma flare-up. His physical assessment shows that his vital signs are typical, he is well-nourished, and he is in no apparent respiratory distress, which reflects that his current health status is good despite the respiratory manifestations.
Contributing Diagnoses: The primary diagnosis that can be made for J. S. is asthma worsening, which is explained by the history of the disease, the presence of symptoms such as wheezing, shortness of breath, and chest tightness, as well as low efficiency of over-the-counter treatment. Another condition that aggravates his condition is allergic rhinitis because he experiences symptoms of a runny nose accompanied by itchy eyes, and examination revealed pale and boggy nasal mucosa. He probably has some underlying chronic history, and environmental factors, such as exposure to smoke from his father’s smoking, would worsen his symptoms. Lack of fever, weight loss, and fatigue rule out an infection as the cause of his illness and indicate that he may have chronic respiratory problems.
Labs: Assessment and confirmation of J. S.’s diagnosis requires several laboratory tests and diagnostic procedures. Since the patient has a severe asthma exacerbation, a peak flow measurement will help determine how bad it is. Some specific functions that can be evaluated by spirometry testing include lung capacity and airway obstruction. Other tests that may be useful would be allergy testing in case he is sensitive to certain products that might be causing his allergic rhinitis. Furthermore, CBC with differential can be done to exclude any running infection or other hematological abnormalities causing his symptoms.
Miscellaneous: J. S.'s social and environmental history is essential in managing his asthma; any exposure to smoke, even outside the home, leads to worsening asthma symptoms; family education on the need to clear all sources of smoke is necessary. The psychosocial aspect is also rather important; while experiencing symptoms, J.S. remains in good spirits and actively communicates; thus, his condition has not affected his psychological state and functioning, apart from expressional and physical activities. It will be crucial to help the family embark on an asthma action plan, ensure the right pharmacological interventions are administered, and make arrangements for follow-up with a pediatric pulmonologist over time to avoid such flare-ups in the future.
Plan:
Differential Diagnoses
1. Asthma exacerbation
2. Allergic rhinitis
3. Viral bronchitis
Principal Diagnoses
1. Asthma exacerbation
2. Allergic rhinitis
Plan
Diagnosis: Asthma exacerbation
Diagnostic Testing: Several tests need to be conducted to get a clearer picture of the severity of J. S.'s asthmatic episode and develop an individualized treatment management plan. A peak flow measurement shall assist in evaluating the current lung status and the procedures' effectiveness (Harb et al., 2020). Additional spirometry will affirm the diagnosis and determine the degree of airway obstruction, which will be vital in long-term management. Dermatological tests may determine specific allergens causing the reactions; thus, a particular avoidant plan may minimize them. The CBC count will exclude any underlying infections or other hematologic abnormalities contributing to coughing.
Pharmacological Treatment: Some medications prescribed to J. S. involve the following: An albuterol inhaler will require PRN every 4 hours to quickly manage symptoms such as wheezing and shortness of breath. Furthermore, fluticasone, an inhaled corticosteroid that must be taken once a day, will help prevent future asthma episodes due to airway inflammation (Jackson et al., 2021). Also, he will be prescribed montelukast 5 mg per day for his allergic rhinitis and the management of asthma. For his nasal symptoms, a fluticasone nasal spray will be added as a solution to the runny nose and itchy eyes due to allergic rhinitis.
Education: Compliance with the established care plan, including a written asthma action plan, will assist in J. S.'s proactive management of asthma symptoms and identify when to seek emergency medical attention from his family. Proper usage of inhalers and spacers can be significant in making sure J. S. is using his medications appropriately. Improving the knowledge of the family on how to prevent further attacks, especially by cessation of smoking, is critical in avoiding reoccurrences of the condition. Stressing the need to take the medicine every day, including the days when J. S. is not experiencing any discomfort, will assist in regulating asthma and preventing episodes when he is sick.
Referrals: Referral to specialists is necessary since there are complexities in the symptoms J. S is experiencing, including asthma and allergic rhinitis. A pediatric pulmonologist will properly treat his asthma, ensuring he has been given the proper treatment. He needs to consult an allergist who will carry out various allergy tests and then diagnose his allergic rhinitis, find out which allergens are likely to be causing the problem, and advise him on how best to avoid them. These referrals will help ensure J. S. receives integrated and proper care related to his respiratory and allergic complications.
Follow-up: The readiness and continuity of care will entail arranging follow-up visits to keep track of J. S.'s responses to the management plan, dealing with any issues, and modifying the plan as necessary. After two weeks, a follow-up appointment with the primary care physician will involve evaluation of symptoms, peak flow, and medication compliance. Subsequent follow-ups with the pediatric pulmonologist and allergist will also be scheduled to provide specialized follow-up care.
Anticipatory Guidance: Educating J. S. and his family on some of the interventions to use when he is experiencing an asthma attack will be beneficial in preventing future attacks. To enhance J. S.'s general physical health and overall well-being, the patient should continue engaging in physical activities, including necessary asthma control medications like albuterol, before performing these tasks. The early signs of an asthma exacerbation should be taught to the family so that they can be able to act appropriately to enable the family to intervene and prevent a full-blown asthmatic attack. It is also essential to ensure they know when it is appropriate to seek emergency medical care if symptoms get worse. It will help avoid asthma flares during allergy seasons if advised on how to handle the conditions and any modification in the use of drugs during those seasons. Advising him to take the flu vaccine at least once a year will assist in avoiding other illnesses that might be risky to his asthmatic state and improve his health generally.
Diagnosis: Allergic rhinitis
Diagnostic Testing: Some tests must be done to confirm the diagnosis and determine particular allergens. Skin prick tests or specific IgE blood tests may help to identify the substances that cause the allergy in J. S. An examination of complete blood count with a differential will ensure that he is not suffering from any other conditions that may be causing the symptoms. Also, a nasal smear is usually taken, and eosinophils are searched, which is typically high in allergy cases (De Corso et al., 2022). These tests will help design unique treatment and avoidance measures for this disease.
Pharmacological Treatment: The medications prescribed to J. S. for managing allergic rhinitis include drugs meant for the control and treatment of symptoms and recurrence of the condition. Fluticasone nasal spray can be used daily to help reduce inflammation in the nose and ease the build-up of thick mucus (Davraj et al., 2021). A tablet he can take orally is cetirizine, which will help reduce his itchiness in the eyes and runny nose. To obtain prompt relief of nasal obstruction, a short treatment course using an oral decongestant may be prescribed. Furthermore, Montelukast (Singulair) can be continued to relieve his allergic rhinitis and asthma.
Education: Education is essential in managing J. S.‘s case of Arthritis Rhinitis. J. S. and his family should be educated on how they can prevent dealing with the irritation. This includes not opening windows during seasons when pollen is present, using an air conditioner, and avoiding things that trigger the problem. Teaching him proper techniques for nasal sprays and medications will ensure that he fully benefits from the treatments. Education on the need to keep using the medication even when he does not have allergic rhinitis symptoms will aid in managing the condition.
Referrals: Appropriate management of J. S.‘s allergic rhinitis is necessary due to its chronicity and interference with daily activities. Therefore, a referral to an allergist who can complete allergy evaluations and provide individualized recommendations is advisable. Moreover, consultation with a pediatric pulmonologist is warranted to ensure proper parallel management of J. S.’s asthma and allergic rhinitis. These referrals will stabilize and enhance the care and support that J. S. and his family need.
Follow-up: Another reason for follow-up visits is to assess how J.S. responds to treatment and adjust as needed. J.S. needs to return to his primary care physician in 4-6 weeks to review his progress, the effectiveness of his medications, and any changes in the symptoms he may be experiencing. Further follow-up visits to the allergist will be important in fine-tuning his allergies, ways to avoid them, and ways to manage them.
Anticipatory Guidance: Anticipatory guidance will assist J. S. and his family in adequately meeting his needs for managing allergic rhinitis. It is, therefore, important that they teach him how to begin identifying some of the early symptoms of an allergic reaction and how to change his medicines. Recommendations for environment control include using dust mite-resistant bedding and avoiding exposure to pet dander, all of which will also assist in minimizing his symptoms. Reminding J.S. of specific measures he had to take, which are essential to tone down specific allergic reactions during the pollen seasons, will be preventive. Moreover, suggestions for annual flu vaccination and proper hand washing to avoid respiratory infections will help prevent the worsening of his symptoms.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Davraj, K., Yadav, M., Chappity, P., Sharma, P., Grover, M., Sharma, S., ... & Gupta, N. (2021). Nasal physiology and sinusitis. Essentials of Rhinology, 49–101.
De Corso, E., Seccia, V., Ottaviano, G., Cantone, E., Lucidi, D., Settimi, S., ... & Galli, J. (2022). Clinical evidence of type 2 inflammation in non-allergic rhinitis with eosinophilia syndrome: a systematic review. Current Allergy and Asthma Reports, 22(4), 29-42.
Harb, H. S., Laz, N. I., Rabea, H., & Abdelrahim, M. E. (2020). Prevalence and predictors of suboptimal peak inspiratory flow rate in COPD patients. European Journal of Pharmaceutical Sciences, 147, 105298.
Jackson, D. J., & Bacharier, L. B. (2021). Inhaled corticosteroids for the prevention of asthma exacerbations. Annals of Allergy, Asthma & Immunology, 127(5), 524-529.
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222