Pediatric – Week 2 Clinical Case Report SOAP narrated PowerPoint

For this assignment, you are to complete a analytic case - anecdotal PowerPoint abode that will chase the SOAP agenda archetype provided below. The case abode will be based on the analytic case book account below.    You are to access this analytic book as if it is a absolute accommodating in the analytic setting.  Instructions: Step 1 - Read the assigned analytic book and application your analytic acumen skills, adjudge on the diagnoses. This footfall informs your abutting steps. Step 2 - Certificate the accustomed advice in the case book beneath the adapted sections, headings, and subheadings of the SOAP note. Step 3 - Certificate all the archetypal affection about associated with the diagnoses in Footfall 1. This advice may NOT be accustomed in the scenario; you are to access this advice from your textbooks. Accommodate APA citations. Example of Accomplish 1 - 3: You absitively on Angina afterwards account the analytic case book (Step 1) Review of Affection (list of archetypal symptoms): CV: sweating, squeezing, pressure, heaviness, tightening, afire beyond the chest starting abaft the breastbone GI: indigestion, heartburn, nausea, cramping Pain: affliction to the neck, jaw, arms, shoulders, throat, back, and teeth Resp: conciseness of breath Musculo: weakness Step 4 – Certificate the aberrant concrete assay allegation about associated with the astute and abiding diagnoses absitively on in Footfall 1. Again, this advice may NOT be given. Cull this advice from the textbooks. Accommodate APA citations. Example of Footfall 4: You bent the accommodating has Angina in Footfall 1 Physical Assay (list of archetypal assay findings): CV: RRR, babble brand 1/4 Resp: beneath animation sounds larboard lower lobe Step 5 - Certificate the diagnoses in the adapted sections, including the ICD-10 codes, from Footfall 1. Accommodate three cogwheel diagnoses. Define anniversary analysis and abutment anniversary cogwheel analysis with pertinent positives and negatives and what makes these choices plausible. This advice may appear from your textbooks. Remember to adduce application APA. Step 6 - Advance a analysis plan for the diagnoses. Only use National Analytic Guidelines to advance your analysis plans. This advice will not appear from your textbooks. Use your analysis abilities to locate adapted guidelines. The analysis plan charge abode the following: a) Medications (include the dosage in mg/kg, frequency, route, and the cardinal of days) b) Laboratory tests ordered (include why ordered and what the after-effects of the analysis may indicate) c) Diagnostic tests ordered (include why ordered and what the after-effects of the analysis may indicate) d) Vaccines administered this arrangement & vaccine administering forms given, e) Non-pharmacological treatments f) Patient/Family apprenticeship including antitoxin care g) Anticipatory advice for the arrangement (be abiding to accommodate absolutely what you discussed during the visit; analysis Bright Futures website for this section) h) Follow-up arrangement with a abundant plan of f/u As you advance your anecdotal PowerPoint, be abiding to abode the belief discussed in the video aloft and the instructions listed below: FOLLOW THE TEMPLATE BELOW for the Analytic Case Abode - SOAP PowerPoint Assignment: DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE. SUBJECTIVE (S): Describes what the accommodating letters about their condition. For INITIAL visits accumulate the advice beneath from the analytic book and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION. Historian (required; unless the accommodating is 16 y/o and older): certificate name and accord of guardian Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old changeable actuality for appraisal of a palmar rash HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, banausic association, severity) accounting in branch form PMH (Past Medical History): Account any accomplished or present medical conditions, surgeries, or alternative medical interventions the accommodating has had. Specify what year they took place MEDs: Account decree medications the accommodating is taking. Accommodate dosage and abundance if known. Inquire and certificate any over-the-counter, herbal, or acceptable remedies. Allergies: Account any allergies the accommodating has and announce the reaction. e.g. Medications (tetracycline-> conciseness of breath), foods, tape, iodine->rash FH (Family History): Account accordant bloom history of actual family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc... SHx (Social history): certificate parent’s assignment (current), educational level, active bearings (renting, homeless, owner), actuality use/abuse (alcohol, tobacco, marijuana, adulterous drugs), accoutrements in-home, accord cachet (married, single, divorced, widowed), cardinal of accouchement in the home (in SF or abroad), how afresh pt immigrated to the US and from what country of agent (if applicable), the gender of animal partners, # of ally in aftermost 6 mo, vaginal/anal/oral, protected/unprotected. Patient Profile: Activities of Circadian Active (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a adolescent is 1y/o or younger, accommodate bearing history also) HRB (Health-related behaviors): ROS (Review of Systems): Asking about problems by agency arrangement systematically from head-to-toe. Included archetypal associated affection (this includes pertinent negatives and positives). OBJECTIVE: Concrete allegation you beam or acquisition on the exam. 1. Age, gender, accepted appearance 2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Accommodate the Growth Chart 3. Concrete Exam: agenda pertinent positives and negatives (refer to the arbiter for archetypal allegation accompanying to present complaint and the analysis you accept the accommodating has) 4. Lab Area – what after-effects do you have? 5. Studies/Radiology/Pap After-effects Area – what after-effects do you have? RISK FACTORS: Account accident factors for the astute and abiding conditions ASSESSMENT: What do you anticipate is activity on based on the analytic case scenario? This is based on the case. You are to account the astute analysis and three cogwheel diagnoses, in adjustment of what is likely, possible, and absurd (include acknowledging advice that helped you to access at these differentials). You charge accommodate the ICD-10 codes, the analogue for the astute and cogwheel diagnoses, and the pertinent positives and negatives of anniversary diagnosis. You are to additionally account any abiding altitude with the ICD-10 codes. NATIONAL CLINICAL GUIDELINES: Account the guidelines you will use to adviser your analysis and administering plan TREATMENT & MANAGEMENT PLAN: Cardinal problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use ammo points, and accommodate A – F beneath for anniversary analysis and G – H afterwards you’ve addressed all conditions. Example: 1. HTN a) Vaccines administered this arrangement & vaccine administering forms given, b) Medication-include dosage amounts and mg/kg for biologic and cardinal of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family apprenticeship including antitoxin care 2. HLD a) Vaccines administered this arrangement & vaccine administering forms given, b) Medication-include dosage amounts and mg/kg for biologic and cardinal of days, c) Laboratory tests ordered d) Diagnostic tests ordered e) Non-pharmaceutical treatments f) Patient/Family apprenticeship including antitoxin care Also discussed: g) Anticipatory advice for abutting well-child arrangement (be abiding to accommodate absolutely what you discussed during the visit; analysis Bright Futures website for this section) Return to the clinic: h) Follow-up arrangement with a abundant plan for f/u and any referrals   CLINICAL CASE SCENARIO A 17-year-old apprentice presents to your dispensary with several canicule of fever, abscessed throat, malaise, and a new adventurous that developed today. She aboriginal started activity ill ten (10) canicule ago with accepted malaise, headache, and nausea. Four canicule ago, she developed a temperature of 103°F that has persisted. She has a deepening abscessed throat and adversity burning solid foods, and she is bubbler well. She denies emesis, diarrhea, or acquaintance with a ailing person. She takes an articulate contraceptive circadian and took two doses of amoxicillin bygone (leftover from a above-mentioned illness). On examination, the accommodating is able-bodied developed with a broadcast morbilliform rash; she appears annoyed but in no distress. Her temperature is 102.2°F, BP 130/80, HR 105, RR 20. She is 64 inches alpine and weighs 120 pounds. She has balmy supraorbital edema, bilaterally continued tonsils coated with gray exudate, a few petechiae on the aficionado and uvula, mutual after cervical lymphadenopathy, and a annoyance that is apparent 3 cm beneath the costal margin. Laboratory abstracts accommodate a white claret corpuscle (WBC) calculation of 17,000 cells/mm3 with 50% lymphocytes, 15% aberant lymphocytes, and a platelet calculation of 100,000/mm3. Diagnosis – Infectious Mononucleosis

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