A 6-year-old previously healthy girl presents to the emergency room with a rash and mouth pain. Her mother took her to see her primary care physician (PCP) 1 week prior with a 2-week history of cough, subjective fever, and malaise.
A 6-year-old previously healthy girl presents to the emergency room with a rash and mouth pain. Her mother took her to see her primary care physician (PCP) 1 week prior with a 2-week history of cough, subjective fever, and malaise. The patient was prescribed amoxicillin for presumed pneumonia. Five days into the antibiotic course, she developed an itchy rash and mouth sores. Her mother reports markedly diminished intake over the previous 24 hours, but no emesis or diarrhea. She has no known medication or food allergies. In the emergency room (ER), her temperature is 102°F (38.9°C), heart rate 122 beats/min, blood pressure 119/73 mm Hg, respiratory rate 18 breaths/min, and oxygen saturation 97% on room air. She is 45 inches tall and weighs 60 pounds. On physical examination, she has bilateral conjunctival injection, ulcers on her tongue and lower lips, and purpuric macules and bullous lesions on her torso and extremities. Chest x-ray reveals an infiltrate in the right lower lobe.
After reading the scenario, answer the following questions in an expanded SOAP note format. You are to type your information directly into the discussion board. You are to address all the questions below. No attachments are allowed:
What is the CC, VITALS, HPI, ROS, and PE findings of this case?
What labs do you want to order? Why do you want to order those labs?
What are 3 differential diagnoses for this clinical case? Why? What clinical data support your differentials?
What is the most likely diagnosis? Identify the clinical data that supports why you believe this is true and provide a rationale for your answer.
As the Nurse Practitioner caring for the patient, what is the next step in this evaluation? What is your treatment recommendation and education for the patient/family? Why? Anticipatory guidance?
The answers to the questions are to be posted following the SOAP NOTE FORMAT below. You are to include the headings and subheadings below in your answer:
SUBJECTIVE
CC:
HPI:
ROS:
MEDICAL HISTORY (if available)
OBJECTIVE
VITALS
PHYSICAL EXAM
RESULTS OF LAB & DIAGNOSTIC TESTS
ASSESSMENT
PRIMARY DIAGNOSIS
2 DIFFERENTIAL DIAGNOSIS
PLAN
TREATMENT
ORDERED LAB and/or DIAGNOSTIC TESTS
REFERRALS
PATIENT/FAMILY EDUCATION
ANTICIPATORY GUIDANCE
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