SOAP note on the approved Pediatric SOAP Note

complete a Comprehensive SOAP note on the approved Pediatric SOAP Note
template based on the findings of the iHuman case – then major research and
discussion of the disease process are presented.

This case study should be a summative evaluation supported by a minimum of 5
evidence-based articles.

Evaluation of the case study should be no more than 3-4 substantive paragraphs- A
minimum of five evidence-based sourm (in addition to your text) should be used for
your case study.

Course texts will not count as a scholarly source; if using data from websites you must
go back to the literature source for the infon’nation-no secondary sources are allowed,
ie, Medscape, UptoDate, etc-

Name: Tommy Acker
Age: 26 months
Sex: M
Height: 2′ 4″
Weight: 22 pounds (BMI 19.7)
Temperature: 97.9 F (oral)
Pulse: 160 bpm – regular
Blood pressure: 68/40 mmHg
Respiratory rate: 50 bpm
SpO2: 93% on room air

Expression: Listless, poor eye contact
Skin: Pale, cool, clammy
Initial position: Lying still on exam table; sucking thumb
Evaluation of Tommy’s height, weight, and BMI:

Height: 28″ = significantly lower than the 5th percentile

Weight: 22# = less than 5th percentile

BMI: 19.7

Key findings
Abdominal pain following a minor fall MSAP
Poor appetite Related
Vomiting x one episode Related
Lethargic Related
Sweaty Related
Rapid breathing/tachypnea Related
Decreased urination; dark, strong-smelling urine Related
Listless, ill appearance Related
Decreased level of responsiveness Related
Tachycardia Related
Hypotension Related
Abdominal distension; epigastric bruising Related
Diffuse abdominal tenderness, guarding, and rebound tenderness Related
Dental caries Related
Down syndrome; global developmental delay Unknown
Atrial-septal defect; status-post surgical repair Unknown
Low-income, single parent with multiple young children Unknown
Small for age; Down syndrome features Unknown
3/6 systolic murmur Unknown
Reducible 2.0 cm umbilical hernia Unknown
Fading (old) ligature marks Unknown
Diaper rash Unknown
Congestive heart failure per history; resolved post cardiac surgery Resolved/PMH

Problem statement
Tommy, a 26-month-old male with Down syndrome, was brought into the ED by his mother who reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic, sweating,
breathing rapidly and has diminished urine output. All symptoms started soon after his “falling out of the bed during his nap.” She denies associated head trauma but claims he is not eating or
drinking. She denies prior injuries that required medical attention. PMH is notable for post atrial-septal defect repair with transient CHF as an infant. The child appears listless and pale. Exam
reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is
firm to palpation with diffuse tenderness, guarding and rebound tenderness. A reducible 2.0-cm umbilical hernia is present.

Differential diagnosis: volvulus vs blunt abdominal trauma vs Hirsch sprung disease vs Henoch schon lein purpura vs child abuse vs traumatic brain injury vs incarcerated hernia vs SIRS

Lab and/or Diagnostic Tests:
Complete blood count: WBC: 19000; HgB: 9; platelets: 60; neutrophils: 81; lymphocytes: 17; monocytes:1; segmented neutrophils: 77
Comprehensive metabolic panel: Sodium: 150; potassium: 6;calcium:7;chloride: 90;carbondioxide: 12; glucose: 130; BUN: 130; creatinine: 2; albumin 2.5; protein total: 4.5; ALP: 25
Lipase: 60
Lactic acid: >4
VBG: venous pH: 7.2; PvO2<65%
PT/INR: 16.5/2.0
UA: Protein 4
Amylase: 115
CT scan of abdomen/pelvis with IV contrast: CT scan of abdomen with oral contrast demonstrates a large central area of edema inclusive of

collections of blood. Marked bowel distension. Findings consistent with duodenal hematoma

Skeletal survey: Upright AP chest and abd x-ray showed acuterib Fx left 8th; healing rib Fx right 4th and 5th; old rib Fx right 9th and 10th.
CT of brain within normal.

Final diagnosis: blunt abdominal trauma, child abuse, SIRS

Patient disposition: admit to pediatric ICU.
Contact social worker and local police. Moms boyfriend admitted to punching tommy in the stomach and throwing him to the bed