Pediatric Soap Note: Bronchitis

Pediatric Soap Note: Bronchitis

Name: T. B.

Date: 02/08/2018

Time: 1030

Age: 2 years

Sex: M

SUBJECTIVE CC: “The child has a running nose, cough, fever, and wheezing.”

HPI: The patient is a 2-year-old male who was brought by her mother to the facility due to a running nose, cough, fever and wheezing. The mother says that the child started presenting with these symptoms last night. The child was given albuterol last night and in the morning. This medication improved his breathing and seemed to reduce coughing bouts.

Her daycare called the mother regarding the other symptoms of sneezing, running nose and fever.

Medications: Albuterol 0.083% tid as needed Singulair 4 mg daily Nasonex 1 spray to both nostrils at night Buy this excellently written paper or order a fresh one from ace-myhomework.com

PMH Allergies: cold Chronic Illnesses: Asthma Medication Intolerances: None Hospitalizations/Surgeries: none Vaccinations: up to date Family History Father: alive and healthy Mother: asthmatic Maternal grandmother –obesity, asthma, and DM II Social History The child lives with her parents, and he is not exposed to secondary smoke since the parents are non-smokers.

ROS

General The patient has a low-grade fever but does not show signs of weight loss. The child has not shown any changes in appetite Skin The child does not have bruises or skin infections Eyes The child does not wear glasses

Cardiovascular The mother states that the child has no known cardiovascular issues Respiratory Mother reports coughing and wheezing. The patient also has a running nose Gastrointestinal The mother denies gastrointestinal problems such as

PEDIATRIC SOAP NOTE: BRONCHITIS

2

Ears The hearing test was performed at birth.

The mother does not report signs of an ear infection

constipation, diarrhea, vomiting, and bloody stool.

The Mother reports normal bowel movements Genitourinary/Gynecological The mother states that the child urinates without any problems.

Nose/Mouth/Throat The child has a runny nose Dental exam six months ago Heme/Lymph/Endo Mother does not report any endocrine- related disorders

Musculoskeletal Mother reports that the child walks comfortably and does not show signs of musculoskeletal deformities Neurological No neurological issues reported. The child can construct simple sentences

OBJECTIVE Weight: 21 lbs BMI 24.9 Temp 98.1 BP: no b/p Height: 28 ½ cm Resp 22 Osat 98.

General Appearance The patient is a 2-year-old male sitting on the mother’s lap. The child is well nourished and does not show developmental abnormalities Skin The skin is skin warm, dry and smooth with no signs of an infection HEENT Head: normalcephalic Eyes: the pupils are round with no detectable infection. Conjunctiva is pink and sclera white. The pupils are reflective to light Ears: the tympanic membrane is intact with no signs of trauma. The external auditory canals are open Nose: clear nasal discharge detected, Neck: the neck is flexible. The tonsils are not inflamed Mouth/Throat: no redness or exudate noted on the throat, the child does not have oral lesions, Cardiovascular Normal S1 & S2. Heart rate and rhythm regular. No clubbing, edema or cyanosis noted. No murmurs and gallops Pulse +2 Respiratory Symmetric chest expansion observed coarse wheezing detected in all lung fields; respiration is regular and unlabored, harsh cough noted Gastrointestinal Normal bowel sound detected The Abdomen is soft, non-distended and non-tender.

No signs of organomegaly detected Genitourinary No palpable masses. No hernia. bilaterally descended testes observed Musculoskeletal Full range of motion detected in all extremities. No muscular pain or discomfort noted Neurological The child is alert, active and does not show signs of distress. The child was talkative during the visit

PEDIATRIC SOAP NOTE: BRONCHITIS

3

Psychiatric: negative Lab Tests Pulmonary function test Special Tests None Diagnosis Primary Diagnosis Bronchitis A diagnosis of bronchitis was made since the child presented with symptoms typical of this condition including coughing, wheezing, and fever (Eber & Midulla, 2013). The child also had shortness of breath and running nose which occurred before a cough. The patient also presented with clear nasal discharge. Another symptom that led to this diagnosis is chest discomfort (Eber & Midulla, 2013).

Differential Diagnoses Asthma A diagnosis of asthma was also possible since the patient had a history of this condition. He also presented with symptoms similar to those of asthma including coughing, wheezing, and shortness of breath (Epocrates, Inc. 2018).

Asthma was however ruled out since the patient did not present with chest congestion, chest pain, and fatigue.

Upper respiratory infection The symptoms of upper respiratory infection are similar to those of bronchitis. These symptoms include a runny nose, a persistent cough, and congestion (Cattamanchi, 2017). This condition was however ruled out since the patient did not present with body aches, fatigue, and a sore throat.

Allergic rhinitis This condition has symptoms such as sneezing, a runny nose, coughing, and a stuffy nose. It was nevertheless ruled out because the patient did not present with watery eyes, hives, and eczema (Moore, 2017) Plan/Therapeutics o Plan:  Further testing Chest x-ray to detect pneumonia-related complications  Medication  Patient to start talking: Orapred 15mg/15ml, 4 ml for severe allergies and breathing problems 

Patient to continue with: albuterol nebulized 0.083% tid for wheezing, coughing, and shortness of breath Nasonex 1 spray to both nostrils at night for a runny nose and sneezing Singulair 4 mg daily for asthmatic symptoms



Education The mother was advised to return to the clinic if the child does not show signs of improvement even after taking the medications. She was also advised to ensure the child is not exposed to extreme cold and other allergens 

Non-medication treatments Ensure the child is well protected from the cold by wearing warm clothes

PEDIATRIC SOAP NOTE: BRONCHITIS

4

Give the child sufficient fluids to minimize the chances of dehydration Ensure the child has sufficient sleep 

Return to office Follow-up 02-10-2018 Self-Assessment & Clinical Guidelines Encounter with the mother was pleasant since she was willing to disclose the health information of the patient besides being eager to learn how to improve the health of the child.

The patient did not require other complex laboratory and diagnostic tests since he did not present with complicated symptoms.

The preceptor noted that pulmonary function test could be performed on children who present with respiratory symptoms such as wheezing shortness of breath and coughing (Hull, 2015).

The previous mediations were not changed since the treatment of this patient was focused on alleviating the symptoms (Hull, 2015). The patient was, however, administered with Orapred which is highly effective in alleviating severe allergic reactions and breathing problems.

The mother was advised to give the child sufficient fluid since clinical guidelines on the In the future, I would request the mother to provide a physical description of the home environment to identify that factors that might increase the child’s risk of respiratory problems. I would also consider giving the child a cough suppressant even though they do not shorten the course of illness.

The patient was not administered with antibiotics since they are not recommended in the management of bronchitis

PEDIATRIC SOAP NOTE: BRONCHITIS

5

References Cattamanchi, A. (2017). Acute respiratory infection. Retrieved from https://www.healthline.com/health/acute-respiratory-disease Eber, E., & Midulla, F. (2013). Paediatric respiratory medicine. Sheffield: European Respiratory Society.

Epocrates, Inc. (2018). Acute bronchitis. Retrieved from https://online.epocrates.com/diseases/13535/Acute-bronchitis/Differential-Diagnosis Hull, J. (2015). Paediatric respiratory medicine. Oxford: Oxford University Press, Moore, K. (2017). Allergic rhinitis. Retrieved from https://www.healthline.com/health/allergicrhinitis