7.4.SOAP NOTE

7.4.SOAP NOTE

Complete a SOAP note for the patient using the SOAP note template as a guide. The SOAP note should NOT be in a table format. This assignment should be done in a single-spaced Word document.

Case Problem Statement for Erin Wilson (on iHuman)

The patient is a 5-year-old female with Trisomy 21 presenting for transfer of care and s/p heart surgery at age 3 months for AV canal defect. Her current history is provided by her mother and includes concerns about her behaviors at preschool, falling asleep in the care and weight gain. ROS is positive for nocturnal enuresis (since birth), snoring (recent worsening) and weight gain. Exam findings elevated BMI, typical phenotype for Trisomy 21, a heart murmur, and enlarged tonsils. The patient’s chromosomal disorder places her at risk for multiple comorbid disorders.

Key Findings

MSAP: Trisomy 21; Mongolian spot; shortened neck; enlarged tongue; transverse palmer crease, hypotonia

Related: Obesity, by BM (>95 percentile) comorbidity, past 12 months per mom.

Related: Loud snoring, new finding, possible sleep apnea.

Related: Developmental delay motor intellectual delay, speech delay.

Related: School anxiety, falling behind peers intellectually, physically, past 4 months.

Bed wetting, chronic possible urinary tract infection or diabetes.

Related: Parental support service reconnection, new to the area, local specialists needed

Related: Nutritional deficiency possible, picky eating, past few months.

Related: Tonsillar hypertrophy

Related: Diastolic murmur

Resolved: Sternal scar secondary to surgery at 3 months of age.

 

Differential Diagnoses

1.      Adjustment disorder

2.      Hypothyroidism

3.      Obesity, childhood

4.      Obstructive Sleep Apnea (OSA)

Ongoing Diagnoses

1.      Down Syndrome

2.      Developmental delay

3.      Nocturnal enuresis