Proofread This Soap Explained for Students (Easy Guide)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to proofread this soap and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves proofread this soap. A strong answer should include explanation, application, and examples.

Original Question

can you proofread this soap note and offer help? Chief Complaint: 3-year-old Black male presents for follow-up on constipation diagnosed 3 months ago and a new complaint of fatigue, irritability, and pallor x 2 months Differential Dx: Iron deficiency Anemia 1. Differential Diagnosis: Iron deficiency anemia Symptoms: Fatigue, Irritability, Poor appetite, Pica, Cold intolerance Signs: Pallor, Tachycardia, Spoon-shaped nails, Systolic murmur 2. Differential Diagnosis: Lead poisoning Symptoms: Constipation, Fatigue, Irritability, Anorexia, Abdominal pain, Behavioral changes Signs: Pallor, Blue-black lead line at the gum line, Developmental delay, Bradycardia, Hypotonia 3. Differential Diagnosis: Constipation related anemia Symptoms: Fatigue, Irritability, Possible abdominal pain or discomfort Signs: Abdominal distension, Hard or impacted stool on physical examination, Signs of dehydration 4. Differential Diagnosis: Hypothyroidism Symptoms: Fatigue or low energy, Constipation, Irritability, Cold intolerance, Poor appetite Signs: Pallor, Bradycardia, Dry, cool skin, Enlarged tongue, Delayed reflexes, Growth delay 5. Differential Diagnosis: Celiac disease Symptoms: Fatigue, Irritability, Constipation or chronic diarrhea, Abdominal pain, Poor weight gain Signs: Pallor, Abdominal distension/bloating, Muscle wasting, Growth delay or failure to thrive SUBJECTIVE HPI Acute Complaint: Fatigue and irritability for 2 months. Activity makes fatigue and irritability worse. Pain reported in LLQ of abdomen but denies pain anywhere else. Abdominal pain reported less intense recently. Moderate to severe change in routine due to symptoms. No previous history of symptoms and no other health care provider seen for symptoms. Grandmother who is caretaker reports pallor of eye and mouth. Denies sleep disturbance. Sleeps between 8 to 10 hours per night. Denies naps but does lay around due to fatigue upon exertion. INTERVAL HISTORY: Onset of Chronic Disease: Constipation diagnosed 3 months ago. Started on Miralax 2 tsp in 8 oz of water daily. Grandmother states he has been compliant with medication adherence. Reports improvement from a score of 1 on the Bristol Stool chart to a score of 2. Reports no medication adverse effects. Plan was to decrease milk consumption from 6 to 7 cups of milk per day down to 2 to 3 cups of milk per day, increase the amount of fresh fruit and vegetables in diet and increase activity. Grandmother reports goals were not met. Patient is still drinking 6 to 7 cups of milk per day, did not increase consumption of fresh fruit and vegetables and is not able to increase activity due to excessive fatigue. Started scheduling toilet time. When did the constipation first begin? What was the plan of care for him? Was any medication prescribed? Has he been compliant with the plan of care and if not, what problems did he have following the plan of care. Were you monitoring his stools? Did he experience any side effects of any medications and if so, what were they? ROS: General: Positive for fatigue after about 15 minutes of play time and fussy when becomes fatigued. Negative for weight loss, appetite changes, slowed growth, coldness, and texture issues. Skin: Positive: pallor. Negative: rash, fever, jaundice, petechiae, bruising, dry skin HEENT: Negative: headache, vision changes, trouble swallowing, mouth sores, sore tongue, ear ache, hearing loss, delayed speech, hoarseness, droopy eyelids, dental enamel defects, delayed tooth eruption, dark circles under eyes, nose bleeds. Positive: conjunctival pallor, mucosal pallor. Cardiac: Negative: tachycardia. Respiratory: Negative: tachypnea, SOA. Neck: Negative: lymphadenopathy, hoarseness, snoring, noisy breathing, swallowing. GI: Negative: appetite change, PICA, diarrhea, bloating, foul smelling feces. Positive: abdominal pain 2 to 3 times per week upon trying to defecate, constipation. GU: Negative: urination issues. Musculoskeletal: Negative: weakness, clumsiness, stiffness, muscle pain. Neurologic: Negative: aggression, hyperactivity, speech and developmental delays, drowsiness, response time, dizziness, . Positive: irritability, hypoactivity. PMH: Allergies: Penicillin causes hives. No food, environmental, latex, or seasonal allergies. Medications: MiraLAX 1 tsp Q/day. No OTC pain medications, vitamins, supplements or herbs Chronic Illnesses: Constipation. No developmental delays or learning disorders. Hospitalizations: No hospitalizations. Surgeries: No surgeries. OB/Gyn: Vaginal delivery at 39 weeks. No complications. No missed OB/GYN appointments. 5lb 7oz at birth, good APGAR scores. Went home 2 days after birth. No tobacco, alcohol or illicit drugs used during pregnancy. Completed all new born screenings. Formula fed. Last well child checkup at 2 yrs. Needs 3 year old well child checkup. Up to date on immunizations. All developmental milestones met on time. Health Promotion: Screenings: Dental visit- never, Optometrist visit- never. (USPSTF, 2021) Immunizations: Up to date until 4-year-old series and schedule. FH: Maternal grandmother: Living 52 years old does have HTN. Maternal Grandfather: Living 54 years old has type II DM. Paternal Grandmother: Living 53 years old has hyperlipidemia. Paternal Grandfather: Living 52 No chronic health issues. Mother: Living 29 years old no chronic health issues. Father Living 30 years old no chronic health issues. No siblings. SH: Occupation: Grandmother retired. Father and mother work at McDonalds during the week and work as delivery drivers on evenings and weekends. Education level: Grandmother high school graduate, mother and father dropped out in 10th grade and never obtained GEDs. Does not attend daycare or preschool. Grandmother plans to start child in preschool at age 4. Living arrangements/pets: Lives with grandmother but sees mother and father on the weekends. No pets in the household. Lives in a rented house with grandmother in town not close to any freeways or industrial sites. Home was built in the 1990s. Born gender, gender identity, preferred pronouns: born male, identifies as male, he/him pronouns preferred. Personal relationships: No trouble making friends but does not get very many interaction opportunities due to not being in school or daycare. Long distance travel by car to play in the park. Family relationships: No family members live close by but grandmother has a couple of friends that live close to her that offer support. ATOD: Grandmother smokes outside of house and car, denies smoking near patient. Grandmother drinks 1-2 beers per week. Grandmother denies illicit drug use. Diet: Dines out 2 times weekly usually when meeting parents at a restaurant. Breakfast usually consists of chicken nuggets, applesauce and milk. Lunch usually consists of a bite of a hamburger, canned peaches with a glass of milk. Dinner usually consists of chicken nuggets, French fries and glass of milk. No water intake except for water given with MiraLAX medication. Tried to incorporate fresh fruit and vegetables but patient refused to eat them. Also drinks milk throughout the day other than with meals. Exercise: Runs, jumps, plays with toys and other children if available at the park. Plays inside at the house due to limited yard space. Hobbies, social activities: Likes to play make believe and has a good imaginationStress, social support: Has grandmother when he feels sick or scared. Grandmother has a couple friends that live close by to help when needed. Social determinants of health: Home was built in the 1990s. No peeling or chipping of paint in home. No concerns about household. Feels safe at home and in neighborhood. Have access to healthy foods and places for the patient to play. No cultural dietary preferences. No religious cultural preferences. No financial concerns. Owns a car. Has transportation to get to medical appointments, grocery stores, and pharmacy. Has adequate health insurance. Has help if child becomes sick. No concerns about child’s development. Grandmother is not aware of WIC, SNAP, Head Start or other available public programs that offer help. OBJECTIVE Vital signs: Temperature 97.6 degrees, HR 102 BP 91/46 RR 24 02 96% on room air height 38 inches 50th percentile, weight 29 pounds 25th percentile, BMI 14.1 3rd percentile, previous height and weights: 2 weeks- length 10th percentile, weight 5th percentile; 2 months- length 10th percentile, weight 10th percentile; 4 months- length 25th percentile, weight 25th percentile; 6 months- length 50th percentile, weight 25th percentile. Length 50th percentile since 6 months of age and weight 25th percentile since 6 months of age. Physical Exam: General: Alert and oriented x 4, No acute distress noted. Sitting in chair, looking through book, appropriate eye contact, reserved but pleasant mood and affect. Well appearance, clean and appropriately dressed. Skin/nails: Brisk skin turgor. Grayish brown skin color. Warm and dry. No rash, bruises or lesions. Brisk capillary refill. Pale nail beds. HEENT: Coarse thick hair, evenly distributed with no dry patches. PERRLA 2mm. Follows light pen appropriately. Clear sclera, pale conjunctiva. Auricles symmetrical, tan, nontender, no drainage, ear canals clear, TM gray, sharp cone of light. Nares patent and moist, but pale, no deviation. No oral lesions, tongue and oral mucosa moist but pale. Tonsils 2+, no erythema, uvula midline, no gingival swelling, no lesions. Pharynx moist but pale. No blue-gray line noted. No macroglossia. Neck: No lymphedema. Thyroid nonpalpable. No goiter. Lymph: No lymphedema. Respiratory: Respirations even, unlabored, no use of accessory muscles. AP diameter 2:1, excursion full and symmetrical. Lungs clear bilaterally. Cardiac: HR 102, tachycardic, regular rhythm, no murmurs. No peripheral edema. No lifts, heaves or thrills. PMI 5th intercostal space left midclavicular line. Abdomen: Abdomen round nondistended. No lesions. Normoactive bowel sounds x4 quadrants. Tympanic sounds throughout. Slightly tender LLQ to palpation. No masses or organomegaly. Musculoskeletal: Normal muscle tone, no hypotonia. Normal gait. Neurologic: No cognitive delay. Clear speech. DTR 3+. No clumsiness, agitation, weakness or ataxia. In -Office Diagnostics Studies/Labs: CBC with diff, iron studies (serum ferritin, serum iron, total iron-binding capacity), reticulocyte count. Assessment: Iron Deficiency Anemia and uncontrolled constipation 1. Differential Diagnosis: Iron deficiency anemia Symptoms: Fatigue+, Irritability+, Poor appetite-, Pica-, Cold intolerance- Signs: Pallor+, Tachycardia+, Spoon-shaped nails-, Systolic murmur- 2. Differential Diagnosis: Lead poisoning Symptoms: Constipation+, Fatigue+, Irritability+, Anorexia-, Abdominal pain+, Behavioral changes- Signs: Pallor+, Blue-black lead line at the gum line-, Developmental delay-, Bradycardia-, Hypotonia- 3. Differential Diagnosis: Constipation related anemia Symptoms: Fatigue+, Irritability+, Possible abdominal pain or discomfort+ Signs: Abdominal distension-, Hard or impacted stool on physical examination-, Signs of dehydration- 4. Differential Diagnosis: Hypothyroidism Symptoms: Fatigue or low energy+, Constipation+, Irritability+, Cold intolerance-, Poor appetite- Signs: Pallor+, Bradycardia-, Dry+, cool skin-, Enlarged tongue-, Delayed reflexes-, Growth delay- 5. Differential Diagnosis: Celiac disease Symptoms: Fatigue+, Irritability+, Constipation+ or chronic diarrhea-, Abdominal pain+, Poor weight gain- Signs: Pallor+, Abdominal distension/bloating-, Muscle wasting-, Growth delay- or failure to thrive- RX: Labs or Diagnostic tests Patient Education Referral Follow-up Health promotion: Screenings Immunizations Constipation: Continue toilet training support: Encourage sitting on the toilet 5-10 minutes after meals, 2-3 times/day. Use a stool under feet to support proper positioning. Positive reinforcement use stickers or charts, avoid punishment. Establish a regular daily routine for toileting. Increase fluid intake especially water. Increase fiber intake with a goal of 8 grams/day. Increase fruits such as pears, prunes and apples. Increase vegetables and whole grains. Limit milk intake to 2-3 cups/day. Avoid processed foods, excessive cheese, bananas, or rice. Polyethylene glycol 2tsp mixed in water or juice BID. Follow up in 4 weeks after starting treatment, Assess stool frequency, consistency, and behavior. Adjust medication dose as needed by 1 tsp per day if stools are soft and frequent. Ongoing follow-up every 1-3 months until symptom resolution and tapering plan is in place. Education: Treatment takes time usually between 3-6 months. Goal is daily, soft, pain-free stools. Do not stop laxatives too early and taper slowly after symptom control. Iron deficiency anemia: Medications/Treatment: Ferrous sulfate 20.1 mg/day of elemental iron in 2 divided doses of 1.3 ml/dose BID. Encourage iron-rich diet such as red meats, leafy greens, fortified cereals, Limit milk intake to 2-3 cups/day, follow up and recheck Hgb, HCT, iron studies and reticulocyte count in 4 weeks. Education: Iron may cause dark stools and worsen constipation, Take iron with vitamin C-rich foods to enhance absorption such as with apple juice or orange juice, avoid taking with milk, place on back of tongue to prevent tooth discoloration. Keep iron out of reach of children due to poisoning risk. Refer to dentist and ophthalmologist. No immunizations needed until 4 year old well child checkup. 3 year old well child checkup needed at next visit. Educate on the available resources for help such as the WIC program, SNAP program, and HeadStart program.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."