CLINICAL CASE SCENARIO
A 5-year-old boy presents to your clinic with a 1-day history of refusing to use his left arm. His father states that his son and his older sister were cared for by a babysitter the previous day. The babysitter said she had been playing with the children in the front yard when the patient ran after a ball that was rolling toward the street. She grabbed the patient’s left forearm and pulled him away from the street. Thereafter, the patient was irritable and holding his left arm close to his body with the elbow in a flexed position. On physical examination, the child has no bony tenderness, erythema, or swelling of the joints, but on passive motion, the child resists and cries in pain. Today, his vitals are as follows: weight 40.5 lbs, height 43.0 inches, BP 110/76, HR 100, RR 26, and Temperature is 98.6 F.
Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
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Example of Steps 1 – 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath