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Case Study Two
Student Name
University
Professor
Date
, 2
CASE STUDY TWO
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.
Case Study Two
Student Name
University
Professor
Date
, 2
CASE STUDY TWO
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.
