Based On The Following Case Study And Using The Sample Uploa

Question

Based on the following case study and using the sample uploaded Based on the following case study and using the sample uploaded, create a SOAP note using references no older than 5 years old: Patient is a 4 years old male, who is brought today for consultation by his mother and grandmother. Parent reports patient has been experiencing redness and swelling of his glans since a few days ago. On the physical examination patient hyperactive, playing, there is swelling and redness of the glans of his penis, no evidence of pus, parent denies fever. We ordered ibuprofen if needed for pain or discomfort, plus oral and topic antibiotics for 7 days.

Dr. Jack HW Helper · Accepted Answer

SOAP Note for a 4-Year-Old Male Patient Subjective The patient is a 4-year-old male who presents to the clinic accompanied by his mother and grandmother. They report that the patient has experienced redness and swelling of the glans for the past several days. The mother notes that while the patient is generally hyperactive and engaged in play, he seems uncomfortable. There is no reported fever, and the mother denies the presence of any discharge or pus. The family is concerned about the appearance of the glans and its potential implications for the patient's health. Objective During the physical examination, the patient is observed to be alert and active, displaying normal levels of engagement typical for his age. Examination of the genital area shows significant redness and swelling localized to the glans of the penis. There is no evidence of pus or exudate, and palpation does not elicit any signs of severe pain. The patient's vital signs are within normal limits, further supporting the absence of systemic infection. The mother's report of the patient's lack of fever is noted and consistent with a physical examination characterized by mild to moderate inflammation without acute distress. Assessment The primary diagnosis for this 4-year-old male appears to be a condition known as posthitis, characterized by inflammation of the glans due to a possible irritant or infection (Wong et al., 2021). The absence of pus and fever suggests that the inflammation is likely not due to a severe bacterial infection. Given the history and clinical findings, there is concern for possible irritant dermatitis or a mild case of balanoposthitis, which can often arise from poor hygiene or excessive moisture (Aydin et al., 2020). The management plan includes measures to alleviate inflammation and monitor the patient for any changes in symptoms. Plan 1. Medication: Prescribe oral ibuprofen as needed for pain or discomfort to help manage inflammation and provide symptomatic relief. Dosage s

Based On The Following Case Study And Using The Sample Uploa ✓ Solved

Based on the following case study and using the sample uploaded

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Subjective

Objective

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