Child facial scar treatment
Child facial scar treatment
Written SOAP Note II 1. Read the following scenario: • Mrs. Epstein and her 11-year-old son, Bart, went to the pediatric clinic with the complaint of sore throat that has lasted for 3 days, along with headache, fatigue, and abdominal discomfort. Bart has taken ibuprofen for his fever and headache. Mrs. Epstein did not take Bart’s temperature; however, he felt hot. Height: 54 inches, weight: 80 pounds; temp: 101; HR 88; RR 20; BP 108/70. When you enter the room, Bart is slouched on the chair falling asleep. On exam you find that he has clear drainage from his nose; erythematous, exudates on tonsils, palpable posterior and anterior cervical nodes as well as occipital and epitrochlear nodes. Spleen enlarged 2 cm below LCM with pain on palpation of LUQ. 2. Write a SOAP note using the scenario above. Develop your SOAP note in a narrative style, as if you were publishing a case study in a journal, avoiding medical abbreviations and jargon. Assume unknown information is normal and document it as such. Assume the patient is an extreme case and consider all possibilities. 3. Identify pertinent positives and negatives. 4. Include a minimum of 2 scholarly peer-reviewed journal articles that support your differential diagnosis and plan. 5. Cite and reference according to 7th edition APA guidelines. 6. References must be from within the last five years. 7.
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All treatment regimens, diagnosis, medications, diagnostic testing, etc… need to have proper reference citations for each item. 8. Textbook for NRP/543: Burns, C. E., Dunn, A. M., Brady, M. A., Barber Starr, N., Blosser, C. G., & Garzon, D. L. (2017). Child facial scar treatment Pediatric primary care (6th ed.). Elsevier. Week 6: Written SOAP Note 2 Grading Criteria Content: 45 points possible Points Possible • Subjective: description of client’s problem/concern Chief Complaint Characteristics – location, radiation, quality, quantity Course – onset, duration, frequency, sequence of events, current status Precursor or aggravators Associated symptoms Treatments or alleviating factors Sequelae – complications, altered life-style Pertinent PMH, FH, P/SH, ROS 10 • Objective: includes P.E. and possible lab data Evaluate body systems reflecting specific complaint location Evaluate body systems that would reflect potential causation Evaluate body system that would reflect potential complications 10 • Assessment Analysis of problem – what it is or what it is not Causation – identifies potential etiology Severity – progression of complications Significance of problem to client – impact on client as a person, cognitive, emotional Ability and motivation of the client, family and caregiver to complete treatment plan 12 • Plan Diagnostic tests Treatment regimen Client (and parent) education Disposition – time of next visit, follow-up activity at next visit, additional diagnostic tests prior to next visit, any referral if indicated 13 Format: 5 points possible Points possible Accurate application of writing conventions enhanced the content. 2.5 Grammar and plagiarism reports uploaded 2.5 Child facial scar treatment
