SOAP NOTE for a Pediatric Patient

Daily Routine:

The mother, who is a single mother of one, usually breastfed the baby when she feels like she is hungry or wakes up. She allows her daughter to sleep 14 to 15 hours a day.

Safety:

The parent ensures that she gives the baby sterilized water whenever she goes. She follows strictly how the baby is handled by strangers or guests. The mother rarely allows the baby to be outside.

Developmental:

The parent states that the child is always weak, has low birth weight, and delayed growth for a two months old baby. The baby has no strong sucking reflex and rarely sucks a few fingers or her fist. However, she bats at colorful materials hanging in her front. Moreover, she briefly holds toys placed in either of her hands. The baby sleeps 14 to 15 hours a day and wakes up between 3 to 4 hours for breastfeeding. The baby sleeps on her backside and uses plenty of tummy time when awake. The baby sees objects and people from as far as 17 inches away. The girl loves to listen to her mother’s voice. The baby makes sweet coos, gurgles, or grunts and recognizes faces. She cries when communicating.

Nutrition:

The mother tries to breastfeed the baby about 8-10 times within the 24-hour period, though the baby is not into feeding. She drinks less than 20 ounces of formula a day.

K.U. is a Caucasian female patient who is presented by the mother to the clinic as an outpatient with several complications. The mother states that her daughter is underweight considering her age and has not been breastfeeding well. She has a delayed growth and is looking weak all the time. The infant has blue coloring on her skin, especially on the fingers, toes, and lips. When being breastfed, the baby gets out of breath. The girl has a feeding difficulty, and she sweats heavily. Apart from that, also she looks fatigued most of the time.

Allergies: The patient has no drug allergies known of.

Medication Intolerances:

The patient has no known medication intolerances.

Chronic Illnesses/Major traumas:

The patient has no known major/minor traumas or chronic ailments.

Hospitalizations/Surgeries:

There are no surgeries/hospitalization records.

Immunizations: Vaccination with age to date include:

The mother, a single parent, is well and alive and has never been diagnosed with any infections. She has four brothers of whom three are well and alive. One of the patient’s uncles was diagnosed with Down’s syndrome. The grandparents are well and alive and have never been diagnosed with major ailments. The information on the paternal side is unknown; the mother does not know the father of her child.

The patient is living with her mother. The information about the father is unknown. The mother is currently 18 years old. Previously, she had multiple partners and cannot guess the father. Still, she is a student in one of the local universities and postponed her studies due to her pregnancy. The mother holds the child tightly when traveling, which she states is a safety precaution on her child.

Constitutional symptoms: The mother admits difficulty in feeding, underweight, and appetite loss. However, she refutes the child having coughs, fever, or diarrhea.

The child appears tired, weak, and at times gets out of breath when feeding.

The mother admits cyanosis. She also states that she almost always hears that the heart of the baby is murmuring. Agrees on the possibility of congenital heart failure.

The mother admits the fingernails and the skin looking blue in color. Moreover, there is excessive sweating on the skin.

The parent admits the possibility of chronic respiratory infection though not sure. She refutes the baby coughing but has rapid breathing.

The mother denies watery eyes, photophobia, conjunctivitis, and cataract.

The parent admits poor weight gain, difficulty in breastfeeding, and low energy. She refutes diarrhea, nausea, or vomiting.

The parent denies the ringing ears of her baby, hearing loss, inflammations, or discharges. The baby is reacting well to the vocal sounds of the mother.

The parent denies her daughter having urination issues, discharge from the vagina, infections, adhesions, pain, lumps, masses, or ulcerations.

The parent admits the baby’s lip being blue in color. Both the nose and throat look normal from any infections or mechanical injury.

The parent denies muscle cramps, back pain, swollen muscles, muscle pain, arthritis, and swollen joints.

The woman denies erythema, lumps, tenderness, lesions, ulcerations, asymmetry, discharge, or infection.

The woman denies paralysis, seizure, vertigo, tremors, or syncope.

The parent denies heat or cold intolerances and anemia but accepts the child being fatigued. Intolerances.

The mother admits less attention but denies nervousness or insomnia.

The patient looks less attentive, has blue coloration on the fingernails and lips, underweight for her age, and has SOB.

There is the presence of blue coloration on the skins, especially on the lips and fingernails.

Head- Unremarkable and Normocephalic. The circumference of the head is 34.01cm.

Nose- Normal.

Ear- Normal.

Eyes- Normal pupils bilaterally, PERRLA.

Throat- There is the presence of bluish discoloration on the lips and mouth (cyanosis).

Rubs and murmurs present, congenital heart failure (tricuspid atresia), as well as irregular heart rate and rhythm heard.

There is the shortness of breath with feeding, no chronic respiratory infection, and rapid breathing.

No abdominal pain, infection, diarrhea, nausea, or vomiting. There is difficulty in feeding.

No erythema, lumps, palpable masses, lesions, or discharges.

Normal external female genitalia, no presence of a hernia, or infection.

Full range of motion, no lordosis, or joint swellings. Negative Ortolani and bar low.

Inactive and less attentive, slow growth, fatigue, and sweating.

Shows distress, inappropriate for age.

· Chest X-ray.

· MRI of the heart.

· Ultrasound of the heart -pending.

· Electrocardiogram-pending.

· Cardiac catheterization-pending.

1. Early Childhood Developmental Screenings to highlight the immediate interventions of the health issue affecting the patient (Moodie et. al., 2014).

2. Ages and stages questionnaire to highlight on the personal-social development, fine motor, problem-solving, and communication of the child (Singh, Yeh, & Blanchard, 2017).

· Tricuspid atresia (ICD-10-CM, Q22.4)

It is the most likely cause of the patient’s ailment based on the manifested symptoms, namely cyanosis, slow growth, heavy sweating, SOB, fatigue, and feeding difficulty. Both MRI and X-ray screening supported the diagnosis.

Differential Diagnoses

· 1- TOF (ICD-10-CM, Q21.3).

The diagnosis was included based on the highlighted symptoms; however, the diagnosis was eliminated based on the findings from chest X-rays, ultrasound, and MRI.

· 2- TAPVC with/without a blockage (ICD-10- CM, Q26.2).

The diagnosis was included based on the patient’s manifested symptoms; however, it was omitted based on the findings from chest X-rays, ultrasound, and MRI.

Vaccine administered on this visit:

The child is supposed to receive polio, rotavirus, pneumococcal, Hep-B, D-T-P group, Hib, and IPV vaccination. Recommendation by WHO on infants with congenital heart disease states that they should receive vaccines just like any other children (Orenstein & Ahmed, 2017).

Vaccine forms Issued:

According to Ventola (2016), it is recommended that educational handouts should always be given to the parents prior to vaccination. Vaccination forms on polio, rotavirus, pneumococcal, Hep-B, D-T-P group, Hib, and IPV were issued to the patient on delivery. Hence, it was easy to relate to the vaccination.

Medications:

To place the patient under systemic-pulmonary artery shunt operation. It involves sewing the Gortex tube, which is between the right pulmonary artery and Subclavian artery. It is through this tube that the blood reaches the lungs with the heartbeats made (Kiran, Aggarwal, Choudhary, Uma, & Kapoor, 2017).

Laboratory tests:

Oxygen saturation test.

Heart catheterization.

(Kosova & Ricciardi, 2017).

Diagnostic tests ordered:

Cardiac Catheterization (Kosova & Ricciardi, 2017).

Chest X-ray.

Parent’s education:

Educate the patient on the risks that come with systemic-pulmonary artery shunt operation. Apart from that, inform the patient on the side effects associated with the surgery (Kiran et. al., 2017).

Non-medication treatments:

To engage the patient in a small less intense exercise like limbs movement.

Based on the nature of the disease, the patient is supposed to be monitored daily until her condition improves.