Peds SOAP #7

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School

Capella University *

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632

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Health Science

Date

Apr 3, 2024

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SOAP Note _______ NU632_______ Herzing University Name:Scarlin Rhoades_________________________ Typhon Encounter #: 4316-20240314- 004 _____________________ Comprehensive:_X___Focused:____ S: SUBJECTIVE DATA CC: Well visit HPI: Patient is a 5-year-old female presenting in the company of her mother for a well visit. Mom reports recent hospitalization for thyroid storm at CHOP. She presented to the ENT for a planned adenoidectomy and during the pre-op visit the doctor notices a goiter and bulging eyes, a large neck mass visualized during intubation. Mother sates she noticed the goiter but did not think it was alarming, her eyes have always been big and bulgy. She is currently taking propranolol and methimazole daily and mom states she notices a significant improvement. PMH: Birth History: Natal: Planned cesarian delivery at 38 weeks 6 pounds weight at birth No complications Past Illnesses Past Medical History : Graves’ disease Hyperthyroidism Seasonal allergies Past Hospitalizations : 03/2023 hospitalized at CHOP for tibial fracture repair Hospitalized from 3/6/2024 to 3/8/2024 at CHOP for tonsillectomy and adenoidectomy, and thyroid storm Past Surgeries: 04/2023 left tibia fracture repair 3/6/2024 thyroid storm Medications patient is currently taking Methimazole 5 mg daily Propranolol 20 mg three times daily Cetrizine 5 mg/ 5 ml once daily IMMUNIZATION S Hep B 11/24/18, 0/5/19, 7/25/19 DTaP 3/5/19, 5/9/19, 7/25/19, 8/10/22 Hib 3/5/19, 5/9/19, 7/25/19, 8/10/22 PVC 3/5/19, 5/9/19, 7/25/19, 8/10/22 PCV13 3/5/19, 5/9/19, 7/25/19, 11/26/19 Hep A 11/26/19, 7/20/20 MMR 7/20/20 Varicella 7/20/20 Flu 11/26/2019

SOAP Note _______ NU632_______ Herzing University Name:Scarlin Rhoades_________________________ Typhon Encounter #: 4316-20240314- 004 _____________________ Comprehensive:_X___Focused:____ GROWTH AND DEVELOPMENT Sleeps 8-9 hours per night Not reading yet, can write her name Continent to urine and stool Does gymnastics once a week ALLERGIES None MEDICATIONS Methimazole 5 mg daily Propranolol 20 mg three times daily Cetrizine 5 mg/ 5 ml once daily SH Patient lives with with her mother and her 7-year-old brother Currently on pre-k FH Mother is 27, healthy Dad is 27, healthy Maternal grandmother, HEALTH PROMOTION & MAINTENANCE Dental exam 01/2024 Eye exam 01/2024 Dermatology- never Uses a booster seat and wears seatbelt in the car Wears a helmet when rides her scooter Uses sunscreen in the summer ROS (put N/A in sections not completed day of exam) Constitutional Denies fever or chills Head Denies isues Eyes Denies pain, discharge, excessive tearing or dryness Ears, Nose, Mouth, Throat Denies ear pain, sore throat Neck Reports goiter Cardiovascular/Peripheral Vascular Reports rapid heart rate, denies edema Respiratory Denies shortness of breath, chest pain, cough Breast Denies pain or concerns Gastrointestinal Denies changes in bowel habits Genitourinary Denies issues Musculoskeletal Denies issues Integumentary Report patches of dry skin Neurological Denies headache, seizures Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) Denies mood changes, anxiety, depression Endocrine Denies excessive sweating,

SOAP Note _______ NU632_______ Herzing University Name:Scarlin Rhoades_________________________ Typhon Encounter #: 4316-20240314- 004 _____________________ Comprehensive:_X___Focused:____ Hematologic/Lymphatic Denies swollen lymph nodes Allergic/Immunologic n/a Other n/a O: OBJECTIVE DATA VITALS: HR: 90 RR: 20 BP: 88/54 Temp: 98.6 SpO2%: Ht: 49.6 in Wt: 21.3 kg BMI: 13.4 Age: 5 LMP: n/a PAIN: n/a Head circumference (HC): n/a PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance Appears calmed, alert, cooperative Head normocephalic Eyes Positive for Proptosis, no jaundice or injection to the sclera, ENT, Mouth, Teeth Ears clear, teeth are well formed, no signs of caries, mucosa moist Neck Goiter visualized and palpated, no lymphadenopathy Cardiovascular/Peripheral Vascular Heart rate and rhythm normal, no murmur Respiratory Lungs clear to auscultate bilaterally, no cough or shortness of breath Breast Breast buds symmetrical, tanner stage I , no palpable masses Gastrointestinal Abdomen soft, non-distended, non-tender, active bowel sounds on all quadrants Genitourinary Male  External Exam n/a  Internal Exam n/a Genitourinary Female  External Exam Tanner stage I

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SOAP Note _______ NU632_______ Herzing University Name:Scarlin Rhoades_________________________ Typhon Encounter #: 4316-20240314- 004 _____________________ Comprehensive:_X___Focused:____  Internal Exam n/a Musculoskeletal Full range of motion to all extremities, normal spine curvature Integumentary Skin dry, intact, no rash Neurological Alert and oriented Psychiatric Cheerful, pleasant Endocrine No lymphadenopathy, no hair growth on body parts Hematologic/Lymphatic n/a Allergic/Immunologic n/a Other n/a A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES PRIORITIZE DIAGNOSIS ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS z00.129 THYROTOXICOSIS W DIFFUSE GOITER W THYROTOXIC CRISIS OR STORM E05.01 VISIT CODES CPT BILLING CODES 99393 DIAGNOSTICS POC TESTING none TESTS REVIEWED Lab work from CHOP P: PLAN ACTIONS 1. Diagnosis: Routine health exam Diagnostics: none Therapeutic: none

SOAP Note _______ NU632_______ Herzing University Name:Scarlin Rhoades_________________________ Typhon Encounter #: 4316-20240314- 004 _____________________ Comprehensive:_X___Focused:____ Education: Encourage variety of choices of fruits and vegetables, encourage hydration now that the weather is getting warmer. Read to her every day Consultation/Collaboration: none 2. Diagnosis: history of thyroid storm Diagnostics Order: none Therapeutic: continue Methimazole and Propranolol as directed Education: continue to follow up with the endocrinologist for management Consultation/Collaboration: Pediatric Endocrinologist 3. Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: PREVENTITIVE (Used for comprehensive exams) Discussed the importance of reading every day Discussed the recommended daily servings of fruits and vegetables Discussed the importance of brushing her teeth twice daily FOLLOW UP As needed 1 year for next well visit

Peds SOAP #7

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