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

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

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.

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)

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