Nursing SOAP Note: Pediatrics Cardiovascular

Name: CH

Present Concerns/CC: “I have had chest pain for four hours.”

CH was well until three days ago he had started experiencing mild shortness of breath after physical activities such as walking and even helping his father in the garden. Today, as he was watching TV, he suddenly started having a dull ache and constant chest pain. He states that the pain was severe, and he rated it at 7/10. He says that it is relieved after rest and aggravated after doing any activity. He also says that the pain was associated with chills, fever, muscle pain, and a pounding heartbeat. CH states that two weeks earlier he had had a severe cold with congestion, sore throat, sneezing, and a mild cough, which had disappeared spontaneously.

Allergies: No known allergies.

Medication Intolerances: He does not react to any drugs.

Chronic illnesses/Major traumas: CH had chickenpox when he was four. He also had bronchitis and pneumonia when he was eight years old. He has never had any chronic lung, renal, or heart disease.

Hospitalization/Surgeries: He was hospitalized when he had pneumonia. He has never had any surgery.

Immunizations: He has had all his age-appropriate immunizations but is yet to receive his annual flu vaccine.

Father- Gouty arthritis.

Mother- Diabetes.

Sister- Mild asthma.

CH is in the 10th grade in the Carling Hill Elementary School. He lives with his parents in a four-bedroom house away from the city in a gated community. The dad drinks alcohol. The family is not exposed to secondary smoke, and they live in a safe environment free from guns and gangs. CH has a comprehensive medical cover.

He has a fever and chills. He has no weight changes or night sweats.

CH has palpitations, exercise intolerance, and chest pain. He has no cyanosis and edema.

CH has no problems with itchy skin, moles, rashes, thinning hair, or brittle nails.

He has mild dyspnea and SOB. He does not have a cough or sputum production.

He denies double vision, use of glasses or lenses, scotoma, tearing, or problems with night vision.

He denies any N/D/V, constipation, bloating, early satiety, stool changes, and abdominal pain.

He has no hearing problems, ear pain, or discharge.

He has not noticed any changes in frequency, dribbling, blood in urine, incontinence, or dysuria.

He has no congestion, nasal sinuses, or sore throat.

CH has myalgia. He denies any muscle redness, cramps, or joint stiffness.

He has not seen any nipple discharge, swelling, pain, or scaling.

He denies any tingling, tremors, seizures, syncope, or weakness.

He has not noticed any bleeding gums or increased bleeding and bruising. His lymph nodes are not enlarged. He denies any heat or cold intolerance, polyuria, polydipsia, appetite alterations, and sweating.

He denies being nervous, depressed, having memory loss, mood changes, or hearing voices.

CH is an adolescent with mild dyspnea and distress due to chest pain. He is well-dressed and well-nourished.

His skin is pale, and he is sweating. There is no ecchymosis, rash, or petechiae.

His head has no deformities; the face is symmetrical, and all sinuses are non-tender. The eyes have pink conjunctiva with no discharge. The orbit has no edema, tenderness, or lesions. The ears have normal external meatus. The tympanic membrane is translucent and grayish. The nose has no polyps, and the sinuses are not edematous. The oral mucosal membrane is dry. No teeth are missing. The throat has no exudates, and the uvula and tonsils are not enlarged.

The heart sounds were clearly heard. CH had an increased heart rate. Extra beats were heard, but there were no murmurs. The PMI was not displaced, and he had no Jugular vein distension.

Chest walls were symmetrical. The breathing was labored. He has tachypnea. On auscultation, both lungs were clear.

The abdomen was soft and not tender when palpated with no masses or organomegaly. The bowel sounds were active in all areas.

Breast examination deferred.

CH had normal external genitalia with descended testis and no hernia or masses. There was no urethral discharge or suprapubic tenderness.

All muscle groups had normal strength, tone, and bulk. He had no joint edema. The movement of all muscles was normal.

All reflexes were normal. He had intact cranial nerves. His gait, posture, and balance were normal.

The patient had direct eye contact during the interview. He answered questions correctly and appropriately.

Echocardiogram-pending

ECG-abnormal with inverted T wave (Hay, Levin, Deterding, & Abzug, 2014).

Chest X-ray-normal

D-dimer test-normal

Complete blood count-normal

Troponin I- elevated

CH lives with his sister and parents. He is an average student in class and manages to pass his exams. He enjoys rugby, football, and swimming. He does not drink alcohol, smoke cigarettes, or use any recreational drugs. He is not sexually active, has never been depressed or had any suicidal attempts or ideas. The home is safe and free from violence and mobs.

1. Acute ischemic heart disease 124.9- positive symptoms are chest pain, SOB, diaphoresis, and palpitations. Negative symptoms are nausea and vomiting, murmur, pain radiating to the arm or jaw, and bradycardia (Hay et al., 2014). The rationale for this differential is that most ischemic heart diseases present with symptoms including dyspnea, palpitations, and chest pain that is dull and achy.

2. Pneumonia J18.9- positive findings are chest pain, dyspnea, and fever. Negatives were a cough, hypoxia, and wheezing. The rationale for this diagnosis is that the patient initially presented with an upper respiratory infection that may have aggravated, resulting in pneumococcal infection. The patient also had chest symptoms that supported this differential.

3. Pulmonary embolism 126.99- pertinent positives – chest pain, fever, tachypnea, and tachycardia. Pertinent negatives – syncope, hypotension, cough, hemoptysis, and hypoxia. The rationale for the differential diagnosis is that the patient had cardiovascular signs suggestive of an embolus in the pulmonary artery. Most patients present with acute symptoms similar to the ones CH presented with, which tend to worsen with time and may lead to medical emergencies (Hay et al., 2014).

Primary diagnosis

Myocarditis 151.4- CH presented with tachycardia, chest pain, fever, and recent nasal infection. His troponin I was elevated, and his ECG was abnormal (Hay et al., 2014).

Establish IV access using two large IV cannulas to help in giving blood or fluids to ensure that the patient is hemodynamically stable (Hay et al., 2014).

Give supplemental oxygen to CH.

Give morphine 4 mg every four hours for pain relief.

Ibuprofen 400 mg IV every four hours as needed for the fever.

The heart should be continuously monitored for any abnormality using an echocardiogram.

Education

The mother should be taught that the symptoms of the condition would subside with or without any heart treatment as the primary cause is a virus. In case of any complications, CH should come and get a referral to a cardiologist.

After the patient’s condition becomes stable and heart function normalizes, he can be allowed to go home but should reduce his sporting activities for at least three months.

The patient should avoid exposure to the virus. He should also receive his annual flu vaccine.

Follow-up

The patient should return to the clinic after two weeks to monitor the heart function and check if the disease was fully cured and that there are no complications.

The patient encounter was successful although the patient was in acute distress. I could elicit various signs that point to cardiovascular disorders. However, it was a bit difficult to establish the final diagnosis from the list of many differentials as the patient’s symptoms were common to many diseases. However, I managed to reach the diagnosis after laboratory tests were performed. This helped me appreciate the importance of laboratory tests in the diagnosis and management of various heart diseases.