Choose two of the pediatric scenarios.
Document an episodic S and O note for each pediatric patient you chose. Include all components of the subjective section that are pertinent. You may fabricate any pertinent information that is not given in the scenario to make it complete, but do not change the intent of the scenario. For example, do not fabricate additional diagnoses or symptoms that may lead to a different diagnosis.
Write a 700-word paper for each patient in which you document the SO portion of a SOAP note and address the following:
- Documentation of all elements of a physical exam using appropriate terminology
- A thorough subjective report, including a list of at least five open-ended questions relevant to the chief complaint you would ask during the HPI exam
- Use descriptive language familiar to the patient
- Include the rationale for asking each question
- Explain why they are appropriate and align to the chief complaint, and include academic resources that support your explanation
- A symptom analysis that identifies all the pertinent positives and pertinent negatives from the HPI (Bates’ Guide to Physical Examination and History Taking, pp. 9, 11, and 80)
- Click the Scenario tab above for a link to the textbook.
- An objective report that documents all relevant specialty tests during the physical exam
- Include at least three rationales for the specialty test
- Include observations you made during the patient interview
- Identify the appropriate ICD-10 codes and E&M codes
- Identify at least two barriers to quality health care the patient might experience based on the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
- Explain how the FNP can address these barriers to improve the quality of care the patient receives.
- Include academic evidence that supports your explanation.
Include a minimum of two peer reviewed academic sources to support your answers, one of which may be your textbook.
Format your paper according to APA guidelines.
Expert Solution Preview
Introduction:
In this assignment, we have been asked to document an episodic S and O note for two pediatric patients and write a 700-word paper for each patient in which we address several components of the SOAP note. These components include a thorough subjective report, documentation of all elements of a physical exam using appropriate terminology, a symptom analysis, specialty tests, relevant diagnosis codes, and barriers to quality healthcare for each patient. We will also provide academic sources to support our answers and format our paper according to APA guidelines.
Scenario 1:
The patient is a 5-year-old male who presents with a chief complaint of fever and cough for the last two days.
Subjective report:
During the HPI exam, I would ask the following open-ended questions to get a better understanding of the patient’s symptoms and chief complaint:
1. Can you tell me more about your child’s fever and cough?
2. When did you first notice these symptoms?
3. Does your child have any other symptoms?
4. Have you given your child any medication for the fever or cough?
5. Has your child been exposed to anyone with similar symptoms?
I would use descriptive language familiar to the patient and explain why each question is appropriate and aligned with the chief complaint. For example, asking about the duration and severity of the symptoms will help me determine the cause of the fever and cough, whether it is viral or bacterial, which will impact the treatment plan.
Symptom analysis:
Pertinent positives: fever, cough
Pertinent negatives: congestion, sore throat, difficulty breathing
Objective report:
During the physical exam, I would document all relevant specialty tests, like a throat swab and auscultation of the lungs. These tests would help me determine if there is an infection and, if so, whether it is viral or bacterial. I would also document any observations I made during the patient interview, like checking for signs of respiratory distress.
Diagnosis and E&M codes:
ICD-10 code: J02.9 (acute pharyngitis, unspecified)
E&M code: 99213 (office or other outpatient visit for the evaluation and management of an established patient)
Barriers to Quality Healthcare:
Two barriers to quality healthcare that this patient might experience are economic and linguistic barriers. The patient’s family may not be able to afford the cost of treatment or medication, which can affect the quality of care the patient receives. Additionally, if the family does not speak English, it may be difficult to obtain accurate information about the patient’s symptoms and medical history. To address these barriers, the FNP can provide resources for affordable healthcare and work with an interpreter to ensure clear communication with the patient’s family.
Academic sources:
Bates’ Guide to Physical Examination and History Taking, pp. 208-217.
Scenario 2:
The patient is a 7-year-old female who presents with a chief complaint of stomach pain and diarrhea for the last two days.
Subjective report:
During the HPI exam, I would ask the following open-ended questions to get a better understanding of the patient’s symptoms and chief complaint:
1. Can you tell me more about your stomach pain and diarrhea?
2. When did you first notice these symptoms?
3. Are you experiencing any nausea or vomiting?
4. Have you been eating or drinking something different lately?
5. Have you been taking any medication for your symptoms?
I would use descriptive language familiar to the patient and explain why each question is appropriate and aligned with the chief complaint. For example, asking about the duration and severity of the symptoms will help me determine the cause of the stomach pain and diarrhea, whether it is viral or bacterial, which will impact the treatment plan.
Symptom analysis:
Pertinent positives: stomach pain, diarrhea
Pertinent negatives: vomiting, blood in stool, recent travel
Objective report:
During the physical exam, I would document all relevant specialty tests, like palpation of the abdomen and assessment of fluid levels. These tests would help me determine the cause and severity of the stomach pain and diarrhea. I would also document any observations I made during the patient interview, like signs of dehydration.
Diagnosis and E&M codes:
ICD-10 code: K52.9 (noninfective gastroenteritis and colitis, unspecified)
E&M code: 99213 (office or other outpatient visit for the evaluation and management of an established patient)
Barriers to Quality Healthcare:
Two barriers to quality healthcare that this patient might experience are cultural and economic barriers. The patient’s family may have different cultural beliefs about healthcare and may not be aware of the available treatment options. Additionally, they may not be able to afford the cost of treatment or medication, which can affect the quality of care the patient receives. To address these barriers, the FNP can provide culturally sensitive healthcare and resources for affordable healthcare.
Academic sources:
Bates’ Guide to Physical Examination and History Taking, pp. 208-217.
