NUR 529
Case Study #2 for Nurse Practitioner Students
Read the following SOAP note about an interesting case written by an NP student:
J.B. is a 3 yobm presenting with: CC: “eyelids and legs are swollen”.
HPI: One month ago, his mother noticed he had swelling of the eyelids and to both legs. He also
had clear, watery nasal drainage. She thought this was an allergic reaction and took him to the
local emergency dept., he was prescribed Zyrtec liquid and discharged home. There been no
improvement and she feels he is getting worse. Associated signs and symptoms include weight
gain, polydipsia, loss of appetite and lethargy. He has gained approx. 5lbs in 1 month. He c/o
of frequent thirst and consumes 8-9 six-ounce glasses of water, juice or whole milk during the
day and wakes up at night thirsty. Was eating well until the swelling started and now eats much
less even when offered preferred foods such as collard greens, peas, bread, broccoli, and fruit.
He is not playing as much and tires easily. No c/o (per mom) of enuresis, polyuria, dysuria,
frequency, urgency, obvious hematuria, unusual color or strong odor to his urine.
PMH:
Birth history: On time vaginal delivery, 40 wks gestational age. No congenital problems or
abnormalities noted on newborn screening. Birth weight 7lbs 3 oz, height 19 inches.
Allergies: Motrin (swelling, edema).
Current Medications: Zyrtec syrup
Illnesses/surgeries: No history of serious illness, feeding problems or developmental delays. Had
a “cold” in January 2009, resolved in 1-week w/o complications.
Tests: Routine metabolic birth screening negative at birth and 2 wks, Lead test negative at 9
months. Immunizations: Up to date: Hep B #1 at birth, #2 at 4 months and #3 at 7 months.
DTap, Hib and PCV at 2 months, 4, 6 and 18 months. IPV at 2, 4 and 18 months, MMR and
Varicella and 15 months.
FH: Mother 26 yobf (homemaker) alive & well, Father 23yobm (office manager) alive & well, 5yo
sister positive for anomalous coronary artery-had surgery (successful) to repair anomaly in
2007 maternal grandmother and maternal aunt positive for Type II DM, Maternal grandfather
died of MI in 1995, paternal grandfather positive for asthma, paternal grandmother alive &
well. Ages of grandparents and aunt not know.
J.W. lives in an apartment w/ his 5yr old sister, mother, father and maternal grandmother.
SH: J.W. stays at home w/ their mother and grandmother. Sister attends kindergarten. Mother
and father smoke, state they smoke outside. Denies ETOH, illicit drugs or guns are in the
, NUR 529
household. Have working smoke detectors and apartment was built in the 1990’s.
ROS: Denies fever or body aches. Denies signs of ear pain such as pulling or digging inside ears.
Denies recent or frequent ear infections. Denies itchy eyes, eye exudates, hx of conjunctivitis,
erythema or flaking of eyelids. No changes in visual acuity noted. Denies epistaxis, nasal
congestion, facial tenderness, positive for rhinorrhea. Denies headache, unusual behaviors,
positive for lethargy. Denies chest pain, SOB, wheezing, adventitious breath sounds, chest
congestion, or hx of congenital cardiac or pulmonary disease. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No c/of muscle pain, back ache or joint pain. Last BM
yesterday, formed and brown. No change in bowel habits.
O
Constitutional: BP 107/72, HR 101, RR 22 unlabored. T 97.8 F°, Wt. 35.20 lbs, Ht. 37.6 in, BMI
th
17/90 percentile for age. Appropriately dressed for the season in clean clothes in good
condition. Well nourished, good hygiene, appears well cared for by parents.
Neuro: Awake, interacts with family and NP student. Gait balance and coordination normal for
age, DTR’s +2 bilaterally, muscle strength equal and symmetrical. Cranial nerves II-XII grossly
intact. Speech 75% intelligible, counts to 10, knows 4 colors, hops on one foot, holds pencil and
draws circle, triangle and cross. Mom reports that he will dress and undress himself and rides a
tricycle easily Red reflex noted bilaterally,
PERRLA. Passed vision and hearing screening.
HEENT: No facial tenderness or masses. Bilateral periorbital edema. Sclera mildy injected, pale
pink conjunctiva. TM’s pearly pink, intact, +cone of light, nares patent w/pale pink mucosa,
small amount of clear discharge in nares, nasal septum midline, buccal mucosa pink and moist,
tongue pink, no furrowing or lesions. Dental caries noted in lower molars. Incisors w/o
discoloration or caries. Tonsils +2, pink, without erythema or exudates. Posterior pharynx
moist pink.
CV: S1S2, RRR, no murmurs, rubs or gallops. +2 pulses in extremities. Cap. Refill <2secs. Skin
warm and dry.
RESP: Even, nonlabored respirations, BBS clear. GI: Soft, distended, liver edge palpable, fluid
wave elicited. Nontender. No organomegaly. Genital: nl circumsized penis, urethral meatus
WNL, no discharge noted, retractable testes, olive sized. MS: Neck supple w/ full ROM.
Extremities: Bilateral +2 pitting edema of shins, ankles and feet.
Labs: Urinalysis: pH 9.0, protein 500 mg/dL and moderate amount of blood. CMP: Na 133 Cl 108
Crea 0.3mg/dL and Total protein 4.9g/dL.
Case Study #2 for Nurse Practitioner Students
Read the following SOAP note about an interesting case written by an NP student:
J.B. is a 3 yobm presenting with: CC: “eyelids and legs are swollen”.
HPI: One month ago, his mother noticed he had swelling of the eyelids and to both legs. He also
had clear, watery nasal drainage. She thought this was an allergic reaction and took him to the
local emergency dept., he was prescribed Zyrtec liquid and discharged home. There been no
improvement and she feels he is getting worse. Associated signs and symptoms include weight
gain, polydipsia, loss of appetite and lethargy. He has gained approx. 5lbs in 1 month. He c/o
of frequent thirst and consumes 8-9 six-ounce glasses of water, juice or whole milk during the
day and wakes up at night thirsty. Was eating well until the swelling started and now eats much
less even when offered preferred foods such as collard greens, peas, bread, broccoli, and fruit.
He is not playing as much and tires easily. No c/o (per mom) of enuresis, polyuria, dysuria,
frequency, urgency, obvious hematuria, unusual color or strong odor to his urine.
PMH:
Birth history: On time vaginal delivery, 40 wks gestational age. No congenital problems or
abnormalities noted on newborn screening. Birth weight 7lbs 3 oz, height 19 inches.
Allergies: Motrin (swelling, edema).
Current Medications: Zyrtec syrup
Illnesses/surgeries: No history of serious illness, feeding problems or developmental delays. Had
a “cold” in January 2009, resolved in 1-week w/o complications.
Tests: Routine metabolic birth screening negative at birth and 2 wks, Lead test negative at 9
months. Immunizations: Up to date: Hep B #1 at birth, #2 at 4 months and #3 at 7 months.
DTap, Hib and PCV at 2 months, 4, 6 and 18 months. IPV at 2, 4 and 18 months, MMR and
Varicella and 15 months.
FH: Mother 26 yobf (homemaker) alive & well, Father 23yobm (office manager) alive & well, 5yo
sister positive for anomalous coronary artery-had surgery (successful) to repair anomaly in
2007 maternal grandmother and maternal aunt positive for Type II DM, Maternal grandfather
died of MI in 1995, paternal grandfather positive for asthma, paternal grandmother alive &
well. Ages of grandparents and aunt not know.
J.W. lives in an apartment w/ his 5yr old sister, mother, father and maternal grandmother.
SH: J.W. stays at home w/ their mother and grandmother. Sister attends kindergarten. Mother
and father smoke, state they smoke outside. Denies ETOH, illicit drugs or guns are in the
, NUR 529
household. Have working smoke detectors and apartment was built in the 1990’s.
ROS: Denies fever or body aches. Denies signs of ear pain such as pulling or digging inside ears.
Denies recent or frequent ear infections. Denies itchy eyes, eye exudates, hx of conjunctivitis,
erythema or flaking of eyelids. No changes in visual acuity noted. Denies epistaxis, nasal
congestion, facial tenderness, positive for rhinorrhea. Denies headache, unusual behaviors,
positive for lethargy. Denies chest pain, SOB, wheezing, adventitious breath sounds, chest
congestion, or hx of congenital cardiac or pulmonary disease. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No c/of muscle pain, back ache or joint pain. Last BM
yesterday, formed and brown. No change in bowel habits.
O
Constitutional: BP 107/72, HR 101, RR 22 unlabored. T 97.8 F°, Wt. 35.20 lbs, Ht. 37.6 in, BMI
th
17/90 percentile for age. Appropriately dressed for the season in clean clothes in good
condition. Well nourished, good hygiene, appears well cared for by parents.
Neuro: Awake, interacts with family and NP student. Gait balance and coordination normal for
age, DTR’s +2 bilaterally, muscle strength equal and symmetrical. Cranial nerves II-XII grossly
intact. Speech 75% intelligible, counts to 10, knows 4 colors, hops on one foot, holds pencil and
draws circle, triangle and cross. Mom reports that he will dress and undress himself and rides a
tricycle easily Red reflex noted bilaterally,
PERRLA. Passed vision and hearing screening.
HEENT: No facial tenderness or masses. Bilateral periorbital edema. Sclera mildy injected, pale
pink conjunctiva. TM’s pearly pink, intact, +cone of light, nares patent w/pale pink mucosa,
small amount of clear discharge in nares, nasal septum midline, buccal mucosa pink and moist,
tongue pink, no furrowing or lesions. Dental caries noted in lower molars. Incisors w/o
discoloration or caries. Tonsils +2, pink, without erythema or exudates. Posterior pharynx
moist pink.
CV: S1S2, RRR, no murmurs, rubs or gallops. +2 pulses in extremities. Cap. Refill <2secs. Skin
warm and dry.
RESP: Even, nonlabored respirations, BBS clear. GI: Soft, distended, liver edge palpable, fluid
wave elicited. Nontender. No organomegaly. Genital: nl circumsized penis, urethral meatus
WNL, no discharge noted, retractable testes, olive sized. MS: Neck supple w/ full ROM.
Extremities: Bilateral +2 pitting edema of shins, ankles and feet.
Labs: Urinalysis: pH 9.0, protein 500 mg/dL and moderate amount of blood. CMP: Na 133 Cl 108
Crea 0.3mg/dL and Total protein 4.9g/dL.
