AM is a 3-year-old Female in Daycare Soap Note

SOAP Note Form
S/ Identifying Information:   (initials, age/DOB, gender, reliability) Family Hx:
Name: AMAge: 3 years

Gender: female

Race:

AM is the firstborn in a family of three. The parents are married and live together but the father works in a retail shop for long hours. The other children are a set of twins who were born prematurely and newborn intensive care unit (NICU) care. The second twin is currently in homecare with a g-tube and oxygen There is no history of parental smoking. No history of known choric illness is reported in the family. AM is a 3-year-old Female in Daycare Soap Note
Personal/Social Hx:
Chief Complaint/RFE: AM started daycare at the age of six months but moved to a new daycare last month. AM is usually playful and speaks well with other people. The mother reports that AM has shown regression generally since moving to the new daycare. She has showed
“Sore throat and fever”
Hx Present Illness: (7 Variables but do not list as such)
AM is a 3-year-old female who has come to the clinic for a sick visit. The mother, who is the informant, reports the baby returned from the daycare three days ago with a mild runny nose. Over the three days, AM has developed gradual fevers, clear nasal drainage, cough, and relapsing fever. The patient also developed a voice change and worsening fevers that reached 103.10F (taken by the mother under the arm). The night before today, the day of the visit, AM woke up crying and had a hotness of body that necessitated the mother to start self-medication The mother gave her Motrin (Ibuprofen) that alleviated the fever temporarily before this visit. The patient also became more irritable and showed a reduction in play and activity. The mother report that AM’s nose is red and irritated and requires help with blowing. The nasal discharge today was noticed to be thick and yellowish. Reduced feeding and energy were also reported today after the child woke up normally. The mother also reports her friend’s child who is AM’s classmate has similar symptoms and was given antibiotics and was relieved. No one in AM’s family has similar symptoms. AM is a 3-year-old Female in Daycare Soap Note

AM is a 3-year-old Female in Daycare Soap Note

CURRENT HEALTH
Medications:  Motrin 7 ml PRN, Tylenol
Allergies: No known food or drug allergies are reported
Last PE & Screenings:  was seen in the good child clinic 2 months ago. The patient has been receiving regular physical examinations since births
Immunization Status: The mother reports the AM’s immunizations are up to date per age
LMP & Birth Control (if applicable): not applicable
PMH
Illnesses & Trauma:  The patient has visited the clinic frequency recently due to respiratory illness complaints. One of these visits was due to a fall
Hospitalizations/Surgeries: the mother reports no previous hospitalizations or surgeries
OB Hx/Sexual Hx: no history of sexual abuse
Emotional/Psych. Hx: AM is usually playful and speaks well the family members and friends. However, since moving to the new daycare, she has been clingy per the mother’s observations. She is irritable and cries a lot in the morning when she is to go to the daycare. The mother reports recent hard times for AM in the new daycare. This morning she woke up later than usual
REVIEW OF SYSTEMS
General: She is generally irritable,
Nutrition: she took two ounces of milk in the morning but did not take any food thereafter
Skin/Hair/Nails: no rash
HEENT:
Breasts:
Respiratory
CV/peripheral vascular
GI: no vomiting or diarrhea
GU
MSK
Psych:
Neuro
Lymph/Heme/Endocrine
O/ Physical Exam: T:        P:        R:        BP:          HT:         WT:         BMI:
General
Skin
Head
EENT
Neck 
Breasts/Chest
Lungs
Heart/ peripheral vascular
Abdomen
Genitalia/Rectum
Lymph
MSK
Neuro
Medical Dx: (2max) Rule Outs (only if applicable):
Health Profile:
age/gender/racial  risks:
Pertinent Positives:(1DX)
personal/family:
screening needs:
Pertinent Negatives: counseling needs:
Immunization/chemo needs:
Differential DX:(3-5)  Alteration in Health Prevention R/T:
Screening deficits:
Counseling deficits:
Nursing Dx Immunization/chemo deficits:
I. PLAN:  Do separate sections in the plan  to include: Max 1-2 pages

Diagnostics:

Medications/Treatments:

Education:

Follow-up:

Referrals:

Prevention Plan:

II. Rationale: ( Max 2 pages)
III. Patho: (Max 2 pages)

Additional History for AM

To make more concise and appropriate diagnoses, I will ask the following question to the mother or patient.

  1. You have stated that AM has visited the outpatient clinic for respiratory complaints, were the symptoms similar to these, during this visit?
  2. Did the child develop teary or watery eyes and if so, do they worsen with seasonal changes?
  3. Tell me more about the cough; is it dry, accompanied by sputum production, worse at night, or associated with chest pain?
  4. Did AM complain of nasal congestion or pressure during these three days? And heat about headache?
  5. Has she complained of abdominal pain or discomfort?
  6. Have you noticed any foul breath in these three days?
  7. Has her hearing reduced since the onset of the illness?

Medical Differential Diagnoses

  1. (J00.0) Acute Nasopharyngitis

Pharyngitis, usually infectious, is an inflammatory illness involving the nose and pharynx and the nasal cavity. Viruses and bacteria are the most common causes of the common cold. Bacterial nasopharyngitis is caused by bacterial micrograms, especially the group A beta-hemolytic streptococci. The common cold is the layman’s term usually used to refer to this type of upper respiratory tract infection. Common viruses causing acute nasopharyngitis include respiratory syncytial virus (RSV), rhinovirus, parainfluenza virus, adenoviruses, coronavirus, and enteroviruses (Thomas & Bomar, 2021 AM is a 3-year-old Female in Daycare Soap Note).

Pathophysiology and Presentation: acute nasopharyngitis, common cold, results from the body’s response to the noxious infectious organisms through inflammation that results in edema, pain, and redness of the nasal mucosa and the pharynx. This inflammation is the body’s response to limit the spread of these organisms and kill the organisms. The inflammation in leads to pain and swelling that causes soreness in the throat. This inflammation also causes vasodilation and increases local vessels permeability and difficulty in the nose and pharynx. The resulting edema and vessel engorgement cause pain and difficulty while swallowing food. Therefore, reduction in feeding and loss of appetite may ensue. The body’s response through acute inflammation causes secretions that included dead cells and phagocytosed microorganisms. Therefore, nasal drainage and foul breath from the mouth, also called halitosis, can be elicited in these patients. Viral infections are known to cause a serous type of acute inflammation that presents as clear discharge. However, acute viral nasopharyngitis progresses with time to cause yellowish thick secretions. This occurs after about two to three days after the onset of the illness. This feature is also similar to acute bacterial nasopharyngitis. Nasal congestion, obstruction, and congestion are among the initial symptoms of nasopharyngitis and if clinically significant may highly suggest a viral etiology of the illness. The inflammation in the pharynx and the nasal cavity may involve the uvula as well. In these cases, the patient may feel a lump during swallowing in the posterior mouth. Inflammation in the nasal cavity causes obstruction. This obstruction may also arise from the accumulation of the exudates from acute inflammation. The patient with, therefore, compensates by mouth breathing that may present as dry mouth and lips, especially in the morning after waking up from sleep. Fever is also another body’s response mechanism towards infection. Fever is common in children but rare in adults with the common cold, both bacterial and viral. In infants and children with viral nasopharyngitis, the body temperature can reach up to 1040F in cases of influenza according to Meneghetti & Mosenifar (2021). This fever can last a few days and resolve on its own but antipyretics may be used to bring the fevers down. Irritation caused by the inflammation of the pharynx may extend to the larynx and cause cough in the common cold. However, rapid local dissemination and direct spread in some individuals may lead to laryngitis or even pneumonia.

The rationale for this Diagnosis: The diagnosis of the common cold is based on the patient’s presentation in the patient’s history. AM’s chief complaints were sore throat and fever. These symptoms were progressive and were later followed by nasal drainage and cough. The fever responded to ibuprofen but relapsed as the strength of the medication wore off suggesting persistence of the underlying etiology. Nasal symptoms present in this patient suggest acute nasopharyngitis but the causation agent cannot be ascertained. According to Meneghetti & Mosenifar (2021 AM is a 3-year-old Female in Daycare Soap Note), history alone rarely provides the distinction between these two major etiologies of acute nasopharyngitis. The presence of fever, cough, thick yellowish nasal discharge, and sore throat makes the diagnosis of acute nasopharyngitis likely in this patient. this is further supported by the absence of a history of recent trauma and familial history of similar illness. Her illness is most likely acquired from the daycare.

Plan:

  • Diagnostics: the diagnostic plan of this disease will include nasal swabs and culture to identify the causative agents of acute nasopharyngitis. Identifying the agent in her age group will be essential because there is a need to rule out streptococci as the underlying cause. The sequala of the streptococci is might include rheumatic heart disease in the feature. Therefore, I think that it will be judicial to perform the culture on the swab while proceeding with the supportive management. More importantly, this patient will require an upper pharyngeal swab for COVID polymeric chain reaction (PCR) tests to rule out COVID-19 as a cause for her upper respiratory symptoms.
  • Treatment plan: The supportive treatment in this patient will include patient education. The mother will be educated on the importance of providing her child with plenty of water to drink and allowing bedrest. I would not prescribe antibiotics for her at this point but I would advise occasional use of Motrin whenever 100mg/5ml oral suspension for the pyrexia. Motrin is a nonsteroidal anti-inflammatory drug that would prevent nay headaches and reduce fevers. However, the mother would be advised not to exceed four times dosing a day. AM will also be educated about regular handwashing and keeping personal hygiene in school and at home (CDC, 2021).
  • Follow-up: She would be followed up after three days to assess the progress of the illness.
  • Prevention plan: The prevention plan will include advising the mother to train the child on sneezing under the elbow or using the handkerchief to prevent spreading the infection. The mother will also keep the child from any smoke or dusty places.
  1. (J01. 90) Acute sinusitis, unspecified

The other medical diagnosis in this patient is acute rhinosinusitis whose presentation may mimic that of acute nasopharyngitis. The inflammation of the paranasal sinuses and the nasal cavity cause the symptoms. Acute rhinosinusitis is also mainly caused by bacteria and viruses but fungal etiologies can be seen immunocompromised. However, the fungal rhinosinusitis is almost likely chronic at the time of presentation. Rhinoviruses, influenzas virus, and coronavirus that cause acute nasopharyngitis are the most common causes of sinus, nasal, and ear infections in acute rhinosinusitis. Other viruses are human parainfluenza, metapneumovirus, RSV, and adenoviruses (Patel & Hwang, 2018). Acute viral rhinosinusitis can cooccur with acute bacterial rhinosinusitis. ABRS is associated with allergies, poor dentition, immune dysfunction, and sinus anatomical narrowing.

Pathophysiology: the inflammation of the nose and the sinuses leads to secretions and mucosal edema that causes the symptoms. The color of the secretions plays little role in suggesting the etiology of acute rhinosinusitis. Sometimes these secretions can be thick with yellow color or remain clear. As seen in the initial stages of acute viral nasopharyngitis. Secretions from the nose and the sinuses may drain anteriorly or posteriorly. Posterior drainage also called the post nasal drip inoculates the pharynx and leads to a sore throat and dry mouth. These secretions cause obstructions in the posterior nasal cavity and lead to mouth breathing that presents with dryness on the mouth and lips. Involvement of the sinuses may be suggested by the facial pressure or pain that accompanies these symptoms. When the presentation of the pain and the other symptoms are unilateral, the presence of sinusitis is highly suggested. The inflammation of the sinuses can progress to affect the internal ear and can present with otitis media. The teeth of the upper jaw can also be involved as a result of infection spread from t the sinuses. Therefore, dental pain and facial pain suggest sinusitis. The postnasal drip also causes the cough seen in acute rhinosinusitis. This cough is usually worse when waking up after sleep because there was time for accumulation of the postnasal drip. A cough that persists throughout the day highly suggests rhinosinusitis (Meneghetti & Mosenifar, 2021). The inflammation of the nasal mucosa can lead to a reduction in the sensation of smell (hyposmia) or lack of sensation of smell (anosmia). Therefore, the presentation depends on the extent of the spread of the infection in the nasal cavity, sinuses, pharynx, and ear.

Rationale and Pertinent Data: The 2013 American Academy of Pediatrics (AAP) set out criteria for the diagnosis of acute bacterial sinusitis. Persistent nasal discharge of any type and color,  severe onset characterized by a fever above 1020F for three consecutive days, and worsening course over the days after initial improvement are the three main criteria required by the AAP guidelines to make the diagnosis of acute bacterial rhinosinusitis in children (Meneghetti & Mosenifar, 2021 AM is a 3-year-old Female in Daycare Soap Note). Acute rhinosinusitis has a biphasic presentation pattern where the individual shows clinical improvement from the cold-like symptoms but then the course of the illness worsens from this improvement. The patient’s mother reports that she showed improvement the morning of the clinic visit but the fever has worsened and the nasal drainage has become thick and yellowish. The patient had a fever of 103.10F as reported by the mother and this is the third consecutive day, she is having the fevers. She partially meets the first criterion for diagnosis she has had persistent nasal drainage; however, the duration does not warrant the diagnosis of rhinosinusitis. This patient has the classical triad of the most common symptoms of acute rhinosinusitis in children: cough, nasal discharge, and fever (Meneghetti & Mosenifar, 2021). In adults, this triad changes and included facial pain, headache, and fever. According to Jaume et al. (2020), nonbacterial and bacterial acute rhodizonates present similarly and would require further diagnostics to identify the causative agents. In most cases, acute rhinosinusitis is caused by a viral illness and would sometimes end up getting superinfected with bacteria (Jaume et al., 2020). Therefore, the presence of bacteria determinism the antibacterial use during treatment. This patient showed probable symptoms of acute bacterial infection such as mucopurulent rhinorrhea.

Plan: Diagnostic plan:

  • I would perform a culture and sensitivity test on the nasal aspirate and pharyngeal swab of this patient to rule out the streptococcal and other bacterial causes of this illness.
  • PCR on the pharyngeal swab would also be sued to rule out COVID-19 as a cause.
  • I would also order erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to establish ascertain the presence of systemic inflammatory response due to the infection.

Treatment plan

  • I would not prescribe any specific antibiotic medication for this patient rhinosinusitis but I would be watchful for the ‘danger’ signs of complications such as otitis media, dental pain, infection of the deep and superficial spaces of the face and neck as ai wait for the culture results.
  • In the meantime, I would prescribe amoxicillin-clavulanate (125mg/31.25mg)/5mL oral suspension. This is broad-spectrum penicillin with beta-lactamase that would empirically inhibit cell wall synthesis in any susceptible bacteria. However, the decision to stop this prescription would be determined by the results of the culture and sensitivity test.
  • This prescription is informed by the worsening of the course of this patient’s illness, persistent fevers, and change in discharge appearance.

Patient Education

  • The patient’s other will be educated to ensure that AM takes plenty of water. Rehydration will be important in replacing the fluids lost through rhinorrhea and insensible water loss worsened by the fever.
  • She would also ensure that AM gets a lot of rest. Adequate nutrition with fruits and verges would also provide additional immunity boosting
  • She will also be educated about the patient’s hygiene, regular handwashing with soap and running water.

Patient Follow-Up

  • The patient will come back again after three days for review. However, she will contact the clinic before these three days if the symptoms worsen or new systems such as ear, dental, or facial pain are identified. During this visit, the patient will be assessed and educated about the natural history of this illness.
  • Referral: when the patient develops dental pain, ear pain, reduced hearing, fascial pain referral to otorhinolaryngologist and dentist will be considered

Prevention Plan

  • I will advise the patient to avoid crowded places and pause the daycare for at least a week to allow recovery. This will prevent the spread of her illness to others or picking another infection leading to superinfection

Differential Diagnoses

Other possible diagnoses in this patient include epiglottitis, coronavirus disease (COVID-19), and separation anxiety disorder.  

(U07. 2) COVID19, virus not identified: This pandemic is also possible in this patient. COVID-19 causes atypical upper respiratory symptoms some of which were seen in this patient (Parasher, 2021). This illness spreads in varied forms of severity: mild, moderate, severe. Sore throat, fever, cough, malaise, and loss of smell are some of the most common symptoms of COVID-19 according to the World Health Organization (WHO, n.d.). Its pathogenesis is similar to the viral acute nasopharyngitis explained earlier. However, its pomposity to spread to the lower respiratory tract is higher. The inflammation in the lower respiratory tracts leads to breathing difficulty (Parasher, 2021). The virus leads to damage to the epithelia and the alveoli. This leads to inefficient aspiration. The pertinent positives in this patient were cough, sore throat, fever, and lethargy. The fever was progressive and lethargy was inferred from the patient’s delay to wake up in the morning the day of the clinic visit. Pertinent negatives were no loss of smell and headaches. This disease was more likely in this patient because the patient had all features of COVID-19. Therefore, there is to distinguish it from the two medical diagnoses aforementioned. PCR would suffice the distinction of this differential from the medical diagnoses. The plan is to rule out this differential through PCR, ensure that patient takes plenty of fluids, eats fruits, and takes enough bed rest.

(J05. 10) Acute epiglottitis without obstruction: acute epiglottitis is common in children, especially children aged between 5 and 15 years (Meneghetti & Mosenifar, 2021). Acute epiglottitis is characterized by the inflammation of the arytenoid folds, epiglottis, and adjacent tissues (Woods et al., 2021). Therefore, it is cellulitis of these structures. Insults such as thermal injury, chemical injury, and local trauma can cause epiglottitis but the role of infections cannot be overlooked. The primary source of infections in epiglottitis can be systemic or local spread from adjacent organs. The pathogenic microorganisms invade the epithelial layer invokes an immune response that results in inflammation. The rich supply from blood vessels and the lymphatic system around the epiglottis favor the survival of these pathogens. The inflammation leads to edema between the epithelium and the cartilage that spreads and the inflammation progresses. In mild cases, there may be no obstruction of the airway. However, the severe forms may be life-threatening due to the obstruction. Four clinical features result from this inflammation known as the 4D’s of epiglottitis: dysphagia, dysphonia, distress, and drooling. The inflammation leads to pain and difficulty during swallowing while the obstruction leads to distress while breathing. The pertinent positives in this patient included a change in voice and a suspected infection source, the sore throat. However, there were no odynophagia, dysphagia, drooling, or distress. To distinguish this disease from the other differential diagnoses aforementioned, an x-ray of the neck and upper airway will be indicated. The thumb sign is pathognomonic of epiglottitis. The rationale for this diagnosis was the change in voice and cough that suggest the progressive spread of the infection from the throat to the lower airway. Moreover, this illness is more common in children than adults. The plan will involve a laryngeal examination using direct laryngoscopy and performing the x-ray radiography of the upper airway and neck. Treatment will still remain rehydration and bed rest.

(J45. 40) Vasomotor rhinitis, a type of nonallergic rhinitis is also possible in this patient. despite the unclear etiologies of this condition, the enhanced cholinergic response causes nasal secretions seen in this perennial type of rhinitis. The rhinorrhea in this illness is believed to be exacerbated by temperature, pressure, and humidity changes. An infectious process can complicate this illness to present with purulent discharge from the nasal cavity. Pertinent positives, therefore, include rhinorrhea and a reddened nose. The absence of isolation of known trigger or infection currently makes vasomotor a likely diagnosis. the plan in this differential would include further history taking and physical examination to gather more information make a diagnosis by exclusion. Complete blood count as a baseline test would also be useful in providing the eosinophil count to rule out allergies as the cause of the symptoms. I would prescribe a topical corticosteroid upon making a firm diagnosis of vasomotor rhinitis. Patient education will concern avoidance of triggers and limiting exposure. Appropriate referral to an otorhinolaryngologist will follow making a firm diagnosis and ruling out the differentials.

309.21 (F93.0) separation anxiety disorder – this mental health diagnosis is also possible in this patient. she doe not meet the full criteria for the diagnosis of separation anxiety disorder in the fifth edition of the diagnostic and statistical manual for mental disorders (DSM-5) (American Psychiatric Association, 2013). The avoidance of school reports that the patient is nowadays clingy suggests separation anxiety. Separation anxiety arises when the individual anticipates separation for an attachment figure who in this case would be the mother. Her reluctance to go to the new daycare would be an anxiety response towards separation. The plan is a referral to a mental health specialist for further evaluation. She has also shown other psychological symptoms that would arrant this referral such as violence in school.

AM is a 3-year-old Female in Daycare Soap Note References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
  • CDC. (2021, December 8). Common cold. Centers for Disease Control and Prevention. https://www.cdc.gov/dotw/common-cold/index.html
  • Jaume, F., Valls-Mateus, M., & Mullol, J. (2020). Common cold and acute rhinosinusitis: Up-to-date management in 2020. Current Allergy and Asthma Reports20(7), 28. https://doi.org/10.1007/s11882-020-00917-5
  • Meneghetti, A., & Mosenifar, Z. (2021, July 15). Upper respiratory tract infection clinical presentation. Medscape.Com. https://emedicine.medscape.com/article/302460-clinical
  • Parasher, A. (2021). COVID-19: Current understanding of its Pathophysiology, Clinical Presentation, and Treatment. Postgraduate Medical Journal97(1147), 312–320. https://doi.org/10.1136/postgradmedj-2020-138577
  • Patel, Z. M., & Hwang, P. H. (2018). Acute Bacterial Rhinosinusitis. In Infections of the Ears, Nose, Throat, and Sinuses (pp. 133–143). Springer International Publishing.
  • Thomas, M., & Bomar, P. A. (2021). Upper Respiratory Tract Infection. StatPearls Publishing.
  • WHO. (n.d.). Coronavirus disease (COVID-19). Who.Int. Retrieved January 29, 2022, from https://www.who.int/health-topics/coronavirus