Write a SOAP Note About Mononucleosis: Fever, Headache (Case Study Sample)

Students Name:
Institution:
Date:
Title: Mononucleosis
subjective:
Mrs. Epstern, the patient's mother, arrived at the pediatric clinic at around 9:30 in the morning with the patient. The patients name was Bart and 11-year-old child who had stated upon inquiry the he had a sore throat that had taken a toll on the child since it’s lasted for three days.
The patient complained of a headache and said that he felt fatigued. Baer also mentioned that he had abdominal discomfort, and he had taken ibuprofen that he hoped would help in with the headache and fever.
CC: (Chief complaint) The patient complained of a severe throat that lasted for three days accompanied by fever, headache, fatigue, and abdominal discomfort.
HPI: (History of present illness) once entering the room I realized that the child’s sitting position was awkward he indeed seemed really tired. After checking the previous records in the files, I noticed that this was their first visit to the clinic.
Since I never found a record of them for the patient or the mother either on of them visited the hospital before. While talking to the parent, it was evident the situation of the child was beginning to worsen as time elapsed. This norm is obvious since even after taking ibuprofen he became even worse. The problem with the ministered drug is that if  one has a liver problem it tends to damage the internal organs
PSM: Past Medical History: The patient claimed that this was the first time he was experiencing this kind of sickness and that he had never experienced such a problem in his early childhood. After inquiring how they came across the powerful drug the parent claimed that she had bought the drug from a local chemist at their place.
MEDs: The prescribed medication was ibuprofen. The drug has adverse side effects in case a person has or is allergic to the drug or has a liver sickness. From the information received the drugs only made the little boy worse.
Allergies: The patient was defiantly allergic to the medication since one of the side effects of the drug is that if the fever lasts for more than three days medical attention is required.
FH: (Family History) upon a close interrogation of the mothers child she claimed that in the family history this was the first time. No one suffered from the disease, so there was no trace of the child’s ancestral lineage.
SHX(Social History) The patient is an 11-year-old child, the child is underage and couldn’t possibly be married or have any kids, Basically the kid is just in school. The child is from a well up family who can take care of the child’s medical condition
HRB: (Health Related Behaviors): After talking to the boy he claimed tat he had never smoked was never on substance abuse and never had any health related problems
OBJECTIVES:
Physical findings
After close examination, these were the findings on the boys age, gender and appearance. The boy’s age is 11.the sex of the child is male, and his physical appearance appeared to be inactive and very fatigued.
Vitals:
The Child had the following: His height was 54 and had an average weight of 80 pounds. The boy had a high temperature of 101 plus his Heart Rate was 88 which was okay. Respiratory rate was 20 which is good for his age, and his blood pressure was 108/70, and that too was a right. In summation, his vitals were okay he only had a temperature.
PHYSICAL EXAM:
Upon close examination, I realized that the boy had clear nose drainage there was redness of the mucous membrane which I supposed was caused either by inflammation or infection. This infection causes an hyperemia of the superficial capillaries
After conducting a Throat Culture as depicted ( Hoffmann, 2006) , which has a percentage of 90-95% accuracy in regards to sensitivity to see if there were any bacteria causing this type of swelling.
I realized that the child’s Tonsils had swollen on both sides covered in yellow after performing an Exudate on his Tonsils. From the sides of his throat, I noticed that his lymph nodes were enlarged since they were quite visible.
I continued my tests and did an X-RAY on the child due to the fatigue like symptoms of the child to find out if the child was suffering from erythema and if so which type? . I sent the boy to the lab to take a blood test to check whether there might be traits of any lurking disease inside the boy but I found nothing.
I examined the palpable posterior which is an artery found on the lower limb which transports blood to the posterior compartment and the planter surface of the foot. I did this in order to check for other vital body symptoms such as the possibility of the peripheral Vascular disease. The child exhibited lessened muscle strength so I performed a head and Neck exam examination from the Top and beneath the (SCM) Sternocleidomastoid Muscles.
Behind the head of the boy and the ears I found out that the boy had swollen, and I realized this must be a viral infection. Still using the same procedure I then realized that the occipital nodes had swollen. Upon examining his Epithrochlear nodes, I realized the two sets of lymphatic nodes near the elbow of each arm elbow that had swollen as shown by Cameron, & MacBean. (1973). All this signs could only link to one disease.
To correct the problem with the abdominal pain, I perpetuated the LUQ (left upper Quadrant) where the boy indicated the response to acute pain. His spleen was bit enlarged which was okay but if it had been over large more than 2cm that would suggest the possibility of splenomegaly. Due to the symptom of the acute pain from the boy I realized there had to be an acute internal obstruction in the bowels (kink sign)
Assessment:
Based on the tests taken above the child is sick and suffers from Mononucleosis (Gedatus, & Dolan, C. (2000). . The prime symptoms of the disease are mainly fever, sore throat, swollen tonsils, weak muscles fatigue headache, and swollen lymph glands showed that the boy was sick.
It's safe to say that the use of the drug that was formerly used did contribute to this level of extreme sickness since the side effects of the drugs were similar to the symptoms of the disease.
Treatment:
The best advice that I gave ...