Soap Pediatric Case Study Six-Year-Old Male Child

SOAP Pediatric Case Study

Six-year-old male child dealing with the persistent cough for about a week and a half. Child complains of mucus being stood up during coughing. He is not been able to sleep the entire night, as if coughing has woken up several times during the past few nights. This morning, he became diapretic and began to cough even worse. The patient has very deep dark circles under his eyes and is showing signs of shivering. The mother took the temperature on a home device of 102°, prompting her to quickly visit the healthcare facility.

The mother has tried to quell the coffee with over the counter child's cough medicine, as well as hot lemon tea and chicken soup. Still, the child's condition has continued only to get worse, with symptoms increasing in severity and duration.

Med HX:

Overall, the little boy is healthy. Yet, there have been significant issues with his health in the past. He has had a history of croup several times in the past, with a case of walking pneumonia reported two years ago that required a short form hospitalization 24 hours. Additionally, the young boy had a case of seasonal allergies in the springtime, as well and a documented case of month.

Meds:

Asthma medication is Albuterol. About two puffs daily PRN. It is currently getting towards springtime, and thus allergies must be kept at bay in order for the child to function well at school. Additionally, the child has been using his inhaler more often than usual. In fact, childhood use it about five times daily since the cop has developed.

Social HX:

The child lives with his two married parents in a non-smoking household. There are two dogs, with the younger sister. The house has recently dealt with illness the other members of the household. In fact, the mother reports having similar symptoms, but to a much less of a degree.

ROS:

The child has been complaining of the cough, as well as thick mucus in his mouth and nose. The cop is beginning to affect both his daily life, as well as his sleeping. The boy is also claiming that he is coughing up green mucus, and has clear soreness in his chest. He's beginning to get overwhelmed with his fever.

Objective Data

Vitals:

BP 110/70, BMP 20, P 118

The child weighs 46 1/2 pounds and is at a height of 48.2 inches. Upon physical examination, it's clear that the child is definitely much paler than in the pictures his mother had shown just previously. Additionally, his mother reports that there is a slight weight decrease, of about 3 pounds since the child's laugh physical three months ago.

HEENT:

Swollen turbinates with clear tenderness and irritation of the let maxillary sinus.

Resp:

The chest exam clearly showed how the child's coughing was not clearing the internal coarse bronchi. There is clear swelling and inflammation within the bronchial tubes. This is suggestive of bronchitis and its typical symptoms of inflammation. An examination of the history and physically of the chest suggests hyperinflation and a clear strong presence of central markings. This is a sign that the diagnosis could either be bronchitis or even a severe asthma reaction.

Labs:

WBC normal

LYM: Normal

MCV: High

MCH: Highe

X-Ray: Normal.

Assessment

Differential Diagnosis:

1. Croup

2. Bronchitis

3. Asthma reaction

4. Pneumonia

5. Influenza

Nursing Diagnosis:

1. Bronchitis

2. Influenza

3. Seasonal Allergy Reaction

The child's immediate family members have recently have had a cold. The child could have picked up the cold, and did not respond to it in time. This then allowed bronchitis to form the same time the child is suffering from mild asthma and allergic reactions during the springtime. With a clear history of bronchitis present in the child's medical report, it is suggested that the child should be diagnosed with bronchitis. Essential diagnosis is acute bronchitis, as has followed a cold or potential viral infection.

Plan

Diagnostic:

Gather more records about his previous cases of bronchitis. You need to be determined whether or not this is acute bronchitis or chronic bronchitis coming back after the child had picked up the same cold family have had. Moreover, the child should undergo more medical tests in order to determine the exact diagnosis. A gram stain and culture needs to be taken. This requires the child to provide mucus for the culture. Additionally, there needs to be the measurement of blood oxygen levels. Influenza and other bacterial tests could also prove beneficial in solidifying the diagnosis as acute bronchitis.

Therapeutic:

The nature of the symptoms and the fact that they are only being exacerbated by the child seasonal allergies requires some additional prescription medications in additional to cost suppressants, such as cough drops that can be found over the counter. First of all, one would be inhaled beta2-agonists, which will help open up the airways and help relieve some of the more difficult coughing. Additionally, Amoxicillin should be prescribed because the boy may be at risk of contracting walking pneumonia again if the inflammatory infection is not handled soon enough.