Nursing

Sex: Male

Age/DOB/Place of Birth: 8 Y/O /04-20-2010/Miami, Florida

SUBJECTIVE

Historian: Dad

Present Concerns/CC:

“He hurt his right arm.”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)

Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.

HPI: (must include all components)

8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.

Medications: (List with reason for med )

None.

PMH:

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Updated

Family History ( Please identify all immediate family)

Father alive and well, mother alive and well.

Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status

He lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.

ROS

General

Denies, headache, chills, myalgia.

Cardiovascular

Denies chest pain/discomfort, heart problems

Skin

Denies rash or lesions.

Respiratory

Denies cough, difficulty breathing, wheezing.

Eyes

Denies discharge from eye, redness, or pain

Gastrointestinal

Denies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.

Ears

Denies pain or discharge

Genitourinary/Gynecological

Denies dysuria or changes in urinary pattern.

Nose/Mouth/Throat

Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing

Musculoskeletal

Reports injury and pain to left arm

Breast

Denies pain or tenderness

Neurological

Denies loss of consciousness, dizziness, headache, or alteration in mental status

Heme/Lymph/Endo

Denies weight loss, activity intolerance, heat or cold intolerance

Psychiatric

Denies depression, anxiety, or suicidal ideation

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight 30.3 kg

Temp 98.9 F

BP 97/59 mmHg

Height 50 in

BMI: 18.74

Pulse 100 x’

Resp 20 x’

Sp02

General Appearance and parent‐child interaction:

No acute distress, well-developed, well nourished, alert.

Skin

Skin pink, warm, and dry, no rashes or lesions noted.

HEENT

Head normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.

Cardiovascular

S1S2 audible. Regular rate and rhythm. No murmurs.

Respiratory

Lungs clear, good air exchange, no wheezes or rales

Gastrointestinal

Abdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly

Breast

Deferred

Genitourinary

Bladder is non-distended; no CVA tenderness, external and internal genitalia not examined.

Pediatric SOAP Note

Musculoskeletal

Limited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.

Neurological

Alert, moves all extremities spontaneously

Psychiatric

Age appropriate development.

In-house Lab Tests – document tests (results or pending)

Right wrist x-ray – closed fracture at distal radius

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

Diagnosis

· 1. Closed fracture of distal end of right radius – S69.91XA

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-ray

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Limited ROM following injury or trauma to the arm suggest possible fracture.

2. Other specified sprain of right wrist, initial encounter – S63.591A

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain.

3. Dislocation of right wrist – M24.331

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation.

·

· Primary diagnoses: Closed fracture of distal end of right radius – S69.91XA

PLAN including education

· Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)

· Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note provided

· Administer Tylenol or Motrin every 4-6 hours as needed for pain.

· Follow-up with Orthopedics, copy of x-ray CD provided

·

References

Arora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.3928/00904481-20140417-12

*ALL references must be Evidence Based (EB)

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