NR 602 Wk2 Soap Assignment

NR 602 Wk2 Soap Assignment

NR 602 Wk2 Soap Assignment

Soap

L.F,15 and 1/2 years, F

S:

CC: “Sports physical, not started menses yet, Birth control pill .

HPI: Kayla brings Lily in for a sport physical, needed prior to the initiation of school, because Lily would like to play volleyball.   Mother is also concerned because Lily has never started her period and is now 15 and ½ years.

Mother is present throughout your initial history gathering.

Lily will be a sophomore. She expresses angst at starting a new school and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual activity upon questioning or use of drugs and alcohol.  She is currently dating a local boy she met for the last month. Her mother reports she would also like to begin Lily on ‘the pill’, because “I don’t want her getting pregnant young like I did”. Her mother remains present throughout the gathering of the history.

Onset:  Not specified. Location: whole body, generalized

Duration: unknown. Characteristics: none

Aggravating Factors: none Relieving factors: n/a

Treatment: n/a.

PMH: full-term vaginal delivery weighed 8 lbs. She experienced a right radial fracture at age 5 and tonsillectomy and adenoidectomy at age 7.

Current medications:  None

Surgeries: None

Allergies: None

Vaccination History:  Mother states, “She had all of her shots up to kindergarten, but I don’t think she has needed any since then

Social history: Lily will be a sophomore. She expresses angst at starting a new school and leaving her friends for the recent move. She sleeps 6 to 7 hours per night. She denies current sexual activity upon questioning or use of drugs and alcohol

Family History: None

ROS

Constitutional: Have you lost or gained weight over time? Do you have change in your appetite? Do you or have you had weakness or fatigue? Do you or have you had any fever or chills?

HEENT: Eyes: Do you have any visual loss, blurred, vision, pain, redness, or discharge from the eyes? Do you wear corrective lenses?  Have you had any trauma to the eyes?

Ears/Nose/Throat: Do you have a hearing loss or changes in hearing? Do you feel any changes in the sense of smell? Do you have sore throat, difficulty swallowing, any postnasal drip, or changes in taste?

Neuro: Do you have headaches, loss of consciousness, dizziness, syncope, or numbness/tingling in the extremities?  Do you have history of sustaining head trauma or concussion? Any  history of loss of consciousness or seizures? Any history of headaches? Have you” or pinched nerve? Do you have any numbness, tingling, or paralysis of limbs? Do you ever drink or use drugs when you’re alone?

Cardiovascular: Have you ever passed out, felt dizzy, had chest pain, palpitations,  heart murmurs, heat illness, or trouble breathing during exercise?

Any recent viral illness that may indicate cardiomyopathy? Are you experiencing excessive fatigue with activities Have you ever had a history of heart problems? Is there a family history of premature or sudden death? Any history of hypertension or any specific cardiac problems in the family?

Respiratory: Have you or do you have any shortness of breath or coughing? Do you have shortness of breath while completing daily tasks and activities? Do you have a history  of asthma, wheezing, dyspnea with activities or other pulmonary problems

Gastrointestinal: Have you had or do you have abdominal pain? Have you had any nausea, vomiting or diarrhea?

Genitourinary: Reports no menses yet. Do you have any abnormal vaginal bleeding? Have you had any irregular bloody virginal discharge? Have you ever used any kind of contraceptive devices or methods? Do you have any difficulty urinating or burning? Have you been diagnosed with UTI? Are you sexually active, if yes, do you have multiple sex partners? Do you use condoms every time you have intercourse?

Musculoskeletal: Do you have muscle weakness, back pain, joint pain, or stiffness? Any history of sprains strains, fractures, tendonitis, dislocations, or subluxations?

Skin: Any skin infections or lesions? Do you have piercings/tattoos?

Hematologic: Do you have fatigue, dizziness, or abnormal bruising or bleeding?

Lymphatics: Do you have any enlarged lymph nodes?

Psychiatric: Lily “expresses” angst at starting a new school and leaving her Do you feel anxious or depressed? Do you have any sleeping problems at night? Have you had any significant changes in your life recently? Have there been any changes in your eating habits? Do you hear any voices or see any unusual things? Are you taking any prescribed or OTC medications/supplements? Have you ever taken diet pills?

Do you have any body image concerns? Have you ever been picked on or bullied?

NR 602 Wk2 Soap Assignment

O: V/S:  Height- 160 cm, Weight- 45 kg, BMI 18.1, (94th percentile) B/P 114/60, HR 90, RR 16, T 98.7, SpO2 99%

Physical Examination of Lily:

Awake, alert, oriented, cooperative. Difficulty with eye contact and answers questions in short 1-2 word answers.

HEENT: Head is normocephalic

PERRLA, EOMs intact, sclera clear, conjunctiva unremarkable. TM’s dull, grey, with cone of light reflex bilaterally.

Nares patent, oral mucosa pink and moist. All teeth present except final set of molars upper and lower. Good dental hygiene. Mucous membranes are moist and pink.

Neck: Neck supply without thyromegaly, normal ROM. No lymphadenopathy.

Pulmonary: Chest wall symmetric, respirations even and unlabored. Lungs CTA.

Cardiac: NL S1, S2. No murmurs or rubs. No JVD. No cyanosis, clubbing, or edema. 2+ pulses bilaterally at the carotid artery. 1+ pulses bilaterally at radial, DP, and PT arteries.  No murmur or change in cardiac status with 1 min of vigorous activity in the office. Femoral and radial pulses equal bil from right to left and upper to lower.

Musculoskeletal: Able to do deep knee bends, heel-to-toe walking, stand on one leg for 10 seconds each, Adams forward bend negative.

Neurological: DTRs 2/5 throughout. MAE. Full active ROM.

Tanner: Breasts tanner III.  Pubic hair Tanner IV

NR 602 Wk2 Soap Assignment

A: Assessment:

Primary Diagnosis

Encounter for examination for participation in sport ICD 10 Z02.5 Components of the physical examination include an evaluation of the spine and extremities. ….

Secondary diff dx

Adjustment disorder with anxiety F43.22 is a stress-related, short-term, nonpsychotic disturbance. The discomfort, distress, …

Personal history of (healed) traumatic fracture (Z87.81)

Lily had a  radial fracture at 5 years old, therefore this examination will focus on the following:

• Detect conditions that predispose the athlete to new injuries.
• Evaluate any existing injuries of the athlete.
• Assess the size and developmental maturation of the athlete.
• Detect congenital anomalies that increase the athlete’s risk of injury.
• Detect poor preparticipation conditioning that may put the athlete at increased risk (Seidel et al., 2011).

Encounter for contraceptive management (Z30) – Kayla is concerned that Lily may get pregnant at a young age, especially now that she is dating a local boy. She is requesting that contraceptives be addressed in today’s visit. This discussion will require a private discussion with Lily as she might open up to me as the healthcare provider. Having a positive attitude towards the adolescent avoiding judgmental responses and establishing to maintain confidentiality may allow Lily to open up (Greenwood,  2012). Her mother reports she would also like to begin Lily on ‘the pill’, because “I don’t want her getting pregnant young like I did”

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Plan:

Lab/diagnostics:

Electrocardiography to evaluate cardiac rhythm and cardiac size. Echocardiography is a screening tool for detecting anomalies that may place the athlete at risk for sudden cardiac death.

Xray: to evaluate the old radial fracture.

Urinalysis, complete blood counts and determination of serum ferritin levels is poor in asymptomatic, healthy sports participants. The results, even if abnormal, do not usually affect sports participation (Sharma, Merghani, & Gati, 2015). I will order these labs instead: A1c, insulin since Lily’s BMI indicate she is overweight, she might be at risk of juvenile diabetes. Estradiol, FSH, LH, Prolactin, TSH, T3 and T4 to determine reason for no menses, pelvic ultrasound.

Medication: I will further assess for signs and symptoms of anxiety and depression before prescribing any medication.

NR 602 Wk2 Soap Assignment

Education:

It important to address Lily’s BMI which indicate that she is overweight. I will advise on healthy diet and exercise in Lily’s daily activities. Lily’s ideal BMI should be between 13.5 and 16.8. I will advise mom on monitoring Lily’s weight to prevent future problem with self-esteem. Teaching Lily that being overweight as an adult increases the risk of serious diseases such as stroke, heart attack, diabetes, arthritis, and some forms of cancer (Stettler, Bhatia, Parish, & Stallings, 2011). So now is the time to teach your child healthy habits that will last a lifetime.

I will educate Lily and mom’s concern about absence of menses at this time. I will let them know that every girl is different as most girls begin menstruating between ages 9 and 18, with an average of around 12 years old (Lobo, 2013). I will educate them on primary amenorrhea which typically occurs when a girl is older than 15, if she has gone through other normal changes that occur during puberty. Primary amenorrhea may occur with or without other signs of puberty. I will advise that Lilly come back for a vaginal/pelvic exam to assess for incompletely formed genital or pelvic organs which could possibly be blockages or narrowing of the cervix, hymen that has no opening, missing uterus or vagina or vaginal septum (a partition that divides the vagina into two sections)(Lobo, 2013). I will also order the following test to rule out possible reason for not having menses at 15&1/2 years old.

I will advise Lily to be positive about changing school and report any issues with bullying at school. I will also advise mom to ensure that Lily is up to date with her immunization.

Referral: Lily may need to see an OBGYN for primary amenorrhea and need for birth control pill.

She may need to see an orthopedic surgeon if Lily complains of any residuals from her fracture e.g, numbness, tingling, loss of balance, double vision etc.

Follow-up: I have Lily return in about 4 weeks to review labs and receive immunization of Tdap, HPV, Menactra, which she missed at 11years old (Stettler, Bhatia, Parish, & Stallings, 2011). May get Influenza if appropriate. Possibly prescribe mediation to help anxiety or any mood concerns, which depends on how much of anxiety Lily still feels or if her mood has progressed to depression.

Recommendation: At this time, I will not clear Lily for sports participation until we see an  xray of her past radial fracture. We also have to determine the extent of the injury  and any effect and if further evaluation with MRI is needed.

NR 602 Wk2 Soap Assignment References

Casey, P., & Bailey, S. (2011). Adjustment disorders: the state of the art. World

Psychiatry, 10(1), 11–18. doi:10.1002/j.2051-5545.2011.tb00003.x

Greenwood, D. C. (2012). Meta-analysis of observational studies. Modern Methods for

Epidemiology, 173–189. doi:10.1007/978-94-007-3024-3_10

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.           (2011). Sports participation evaluation. Mosby’s Guide to Physical                     Examination, 749–759. doi:10.1016/b978-0-323-05570-3.00023-0

Sharma, S., Merghani, A., & Gati, S. (2015). Cardiac screening of young athletes prior       to participation in sports. JAMA Internal Medicine, 175(1), 125.                       doi:10.1001/jamainternmed.2014.6023

Lobo, R. A. (2013). Primary and secondary amenorrhea and precocious puberty.              Comprehensive Gynecology, 815–836. doi:10.1016/b978-0-323-06986-1.00038-x

Marsden, J. (2014). Mosby’s manual of diagnostic and laboratory tests: Pagana                 Kathleen and Pagana Timothy mosby’s manual of diagnostic and laboratory tests. Elsevier. Emergency Nurse, 22(4), 13–13.  doi:10.7748/en.22.4.13.s14

Stettler, N., Bhatia, J., Parish, A., & Stallings, V. A. (2011). Feeding healthy infants, children, and adolescents. Nelson Textbook of Pediatrics, 160–170.e1. doi:10.1016/b978-1-4377-0755-7.00042-7