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SOAP

A child presented with vomiting and loose bowel movements was diagnosed with acute gastroenteritis likely caused by a virus. Examination found the patient febrile but otherwise stable. Treatment of oral rehydration and antipyretics was prescribed. A second child diagnosed with congenital heart disease called total anomalous pulmonary venous return was also examined and found cyanosis but stable. Echocardiogram confirmed the diagnosis and treatment with digoxin was continued. A third malnourished child with poor intake and severe wasting was prescribed nutritional supplements. A fourth problem involved financial difficulties.

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Reda So
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72 views1 page

SOAP

A child presented with vomiting and loose bowel movements was diagnosed with acute gastroenteritis likely caused by a virus. Examination found the patient febrile but otherwise stable. Treatment of oral rehydration and antipyretics was prescribed. A second child diagnosed with congenital heart disease called total anomalous pulmonary venous return was also examined and found cyanosis but stable. Echocardiogram confirmed the diagnosis and treatment with digoxin was continued. A third malnourished child with poor intake and severe wasting was prescribed nutritional supplements. A fourth problem involved financial difficulties.

Uploaded by

Reda So
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Problem number 1: Vomiting, Loose bowel movement

S: (+) febrile episode (+) poor oral intake (+) diarrhea (+)vomiting
O:
General Appearance: Patient is awake, febrile, not irritable, and not cardiorespiratory distress
Vital Signs: CR: 118 beats per minute RR: 25 breaths per minute Temperature: 37.9 °C
SPO2 at room air 88%
Skin: (-) pallor, (-) cyanosis, (-) jaundice, warm to touch, with fair skin turgor
HEENT: (-) gross deformities, (-) trauma, normal hair distribution (-)CLAD
Eyes: anicteric sclerae, pink palpebral conjunctivae, sunken eyeballs, (-) periorbital edema
Ears: symmetrical ears, (-) discharges , (-) impacted cerumen, intact tympanic membrane
Nose: (-) discharges, (-) congestion, (-) alar flaring
Mouth and pharynx: dry lips, moist buccal mucosa (-) circumoral cyanosis, (-) TPWC
(-) ulcers, (-) exudates, (-) enanthems
Neck: (-) supraclavicular and suprasternal retractions, (-) palpable cervical
lymphadenopathies
Abdomen: flat, non-distended, hyperactive bowel sounds, tympanitic, soft, non-tender, no masses
A: Acute Gastroenteritis, probably viral
Plan: DX: Stool exam
Thereapeutics: D5LRS 1L 125 ugtts/min due for RA after 6 hours
Paracetamol 125mg/5ml, 5ml q4 PRN for temp>37.8C
Zinc Sulfate drops 2ml once a ady

Problem 2: Congenital heart disease, cyanotic type, TAPVR


S: Diagnosed with a congenital heart disease; 2D Echo diagnosis of TAPVR
O: General Appearance: Patient is awake, febrile, not irritable, and not cardiorespiratory distress
Skin: (-) pallor, (-) cyanosis, (-) jaundice, warm to touch, with fair skin turgor
HEENT: (-) gross deformities, (-) trauma, normal hair distribution (-)CLAD
Eyes: anicteric sclerae, pink palpebral conjunctivae, sunken eyeballs, (-) periorbital edema
Ears: symmetrical ears, (-) discharges , (-) impacted cerumen, intact tympanic membrane
Nose: (-) discharges, (-) congestion, (-) alar flaring
Mouth and pharynx: dry lips, moist buccal mucosa (-) circumoral cyanosis, (-) TPWC
(-) ulcers, (-) exudates, (-) enanthems
Neck: (-) supraclavicular and suprasternal retractions, (-) palpable cervical
lymphadenopathies
Chest and Lungs: Has pigeon chest; symmetrical chest wall expansion, (-) subcostal retractions, (-)
crackles
Heart: dynamic precordium, PMI at 5th ICS LMCL, normal rate, regular rhythm, positive thrills, (+)
systolic murmurs, more on the midsternal area and below the sternum
Extremities: no gross deformities, full and equal pulses good capillary refill; cyanotic nail beds
A: Congenital heart disease, cyanotic type, TAPVR
Plan: DX: no plans
Therapeutics: Lanoxin Elixir 1ml BID

Problem 3: Malnutrition
S: Poor oral intake
O: Weight: 9.3 kg Height: 82.5 cm
Wasting: 9.3 / 11.18 kgs x 100 = 78.81 severely wasted
Stunting: 82.5 / 85.4 x 100 = 96.60 not stunted
A: Malnutrition
P: Ceelin syrup 2.5ml once a day
Ferlin syrup 1.5ml once a day

Problem 4: Financial difficulties

Prepared by: JI DACANAY, Emilleo A.

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