NRNP 6568 Week 9 Assignment; Diagnosing, and Treating Special Populations..

Soap Note Week 9 Student Name Walden University NRNP 6568 Dr Daphne Sharpe Soap Note SUBJECTIVE Patient Information: Patient Initials: AN Age: 9 Years Old Sex: Female Race: American CHIEF COMPLAINT (CC): “runny nose, For Annabelle, 99.4 degrees is a high fever.” HISTORY OF PATIENT ILLNESS (HPI) AN is a 9-year-old girl whose mother accompanies her to the hospital. The mother states that AN, for the past three days, has been having a running nose. Additionally, ANs mother says that AN woke the previous night complaining of pain in the right ear. The mother took her temperature orally. The temperature was 99.4 degrees Fahrenheit which is equivalent to 37.44 degrees Celsius. Therefore, she decided to give AN Tylenol which helped reduce the temperature. AN’s temperature reduced to 98 degrees Fahrenheit, which is equivalent to 36.667 degrees Celsius. The mother is concerned about AN temperature of 97.0 degrees Fahrenheit, equivalent to 36.11 degrees Celcius. According to her, 99.4 degrees Fahrenheit is a high fever. The mother also states that AN is not eating well but is drinking well. The mother also says that AN has had a couple of loose stools which did not have blood. PAST MEDICAL HISTORY (PMH) Allergies: No known allergies Current medications: Tylenol. Injuries: no known injuries Patient’s Illness: fever. Information Related to Past Surgical Procedures (PSP): no known Surgical Procedures. Family History (FH): AN’s family history is not known. There are no details about the siblings and the father. However, we know that she has a mother. The mother’s health status is not known. Social History (SH): AN social history is not known. There are no details that show the patient’s relationships with friends or family members. Review of Systems (ROS): Constitutional: Positive for runny nose, pain in the ear, loss of appetite, loose stool with no blood. HEENT: Positive for pain in the ears and running nose, negative for ear discharge. Head: Normal. Eyes: Normal. Right Ear: Pain, negative for discharge. Left Ear: Normal. Nose: Running nose. Mouth/ Throat: Normal. OBJECTIVE Physical exam Vital Signs: Oral temperature 99.1, AHR 110, RR 18 Constitutional: General: AB is not in acute distress Appearance: AB looks sick and is sitting quietly with a frown HEENT: Head: Normocephalic. Eyes: Negative. Right Ear: Pain, negative for discharge, the tympanic membrane is gray, no tinnitus on changes in normal hearing, external auditory canal blocked by a popcorn by two-thirds, redness, and slight swelling in the canal. Left Ear: Tympanic membrane is normal, no tinnitus on changes in normal hearing, no pain. Nose: Negative Mouth/ Throat: Negative. Rate and Rhythm: 18. Temperature: 99.1 F ASSESSMENT Foreign Object into the ear Rationale: According to Moorthy, Srivalli, Rau,& Prasanth (2012), one of the major problems affecting children is having a foreign object in the ear and the nose. This problem does not only affect children but also adults. However, this problem is more common in children than adults (Awad & ElTaher, 2018). According to Olajuyin & Olatunya (2015), children under eight years are the