Soap Note narrated PowerPoint.

Pediatric SOAP Note

NP Student Name: Stacy Martin Child’s Initials: A.D. DOB: 06/15/2009

Clinical Date: 12/11/2019 Age: 10 Place of Born: Graceville, FL

Week Soap Project: W2

Sex:

M ___

F _X__

Type of Soap Note:

Well child visit ____

Sick visit __X__

SUBJECTIVE

Historian: Patient and Father

Present Concerns/CC: “I am here today because I have a cough, runny nose, and sore throat.”

Child Profile:

Activities of Daily Living ( a g e a pp r o p r i at e) : The child is able to feed, bathe, and dress herself

independently. The patient states that she has two chores which include making her bed every morning

before school and helping walk and feed the family dog. The patient states that on school nights she goes

to bed between 8:30-9:00pm and on the weekends she goes to bed at 10:00 pm.

S a f e ty Pr act i c e s : The patient states that she wears herself when riding in the car and states that she rides

in the back seat. The patient also states that she wears a bicycle helmet when riding her bike around her

neighborhood.

C h a n ge s i n d a y ca r e / s c h ool /a f t e r-s c h oo l ca r e : Denies any changes in school.

S p o r t s / ph y s ical ac t i vi t y : The patient states that she is currently in band at school and plays the tuba.

D e v elo p m e n tal History : Child has achieved all development milestones.

S ex u al H i s t o r y (i f a p p r o p r i at e ) : Denies.

HPI: The patient reports having nasal congestion, cough, and a sore throat for the past two days. The

patient describes her nasal drainage as clear and started off with a very little amount but has increased to a

moderate amount in the past two days. The patient reports the nasal congestion to be constant for the past

two days. The patient reports trying over-the-counter nasal spray for her nasal congestion with no relief.

The patient also reports a dry, nonproductive, “barking” cough. The patient reports an increase in the

intensity of the cough over the past two days. The patient states that she experiences the cough constantly,

Revised 5/9/18; 8/9/18; 10/29/18;10/22/19

Pediatric SOAP Note

with intensity increasing at night time. The patient states that she tries changing positions to help with the

cough, with no relief. The patient states that she has noticed an increase in shortness of breath during the

cough and during exertion. The patient also complains of a dry, burning, aching, sore throat. The patient

reports that the intensity of her sore throat has increased over the past two days. The patient reports trying

Halls cough drops with minimal relief. The patient reports that the pain in her throat is constant, lasting all

day, and increasing at night.

Medications: Omeprazole 20mg Daily- GERD

Ondansetron 4mg PO every 8-12 hours PRN- Nausea

Prednisone 20 mg PO- 1.5 tablets BID

Albuterol Sulfate 2.5mg/3 mL nebulizer solution every 4-6 PRN- Shortness of breath and wheezing

PMH:

Allergies:

Chronic Illnesses/Major traumas: GERD, allergic rhinitis

Hospitalizations/Surgeries: Tonsillectomy 2014

Immunizations:

Fluzone, Quadrivalent 5.0mL Multidose Vial- 1/24/2018

Family Medical History:

Father- Alive- GI Ulcer, Anxiety, GERD

Mother- Alive- Thyroid disease, Asthma

Social History

Cu r r e n t li vi n g s it u a t io n / pa r t n e r / m a r i t a l s t a t u s : The patient currently lives with her mother,

father, 3 cats, and 2 dogs.

E d uc a t io nal le v e l (as appropriate) : The patient is currently in 4th grade.

O cc up a t i on a l h i s t o r y (as appropriate) : N/A

S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): Patient denies alcohol and substance

abuse.

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Pediatric SOAP Note

Firearms in home: Patient’s father denies firearms in house.

S a f e ty s t a t u s : The home is protected without firearms. The patient states that she does not stay home

alone for any period of time. The patient states that she knows to lock the doors, not talking to

individuals that she doesn’t know, and lets her parents know everything that she is doing.

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Pediatric SOAP Note

REVIEW OF SYSTEMS

(Do not omit any body system & remember this is a child not an adult)

General: Reports increased fatigue over the past

2 days. Denies fever, difficulty sleeping, night

sweats, unexplained weight gain/weight loss.

Cardiovascular: Reports chest pressure when

coughing. Denies chest pain. Denies swelling,

palpitations.

Skin: Denies eczema, itching, or dryness.

Denies bruising easily. Denies hives, lumps, or

moles.

Respiratory: Reports shortness of breath and

coughing. Denies asthma, bronchitis, coughing up

blood. Denies productive sputum.

Head: Denies dizziness, fainting, or head injury.

Denies headache, pain, sweats, and swelling.

Breast: Denies discharge, lumps, pain, and

tenderness.

Eyes: Denies blurred vision, discharged, double

vision, and excessive tearing. Denies eyes pain,

use of glasses, redness, or recent infection.

Gastrointestinal: Reports occasional heartburn.

Denies abdominal pain, constipation, diarrhea,

changes in bowel movements. Denies change in

appetite, excessive thirst, nausea, rectal pain,

swallowing impairments, and vomiting.

Ears: Denies discharge, dizziness, hearing

impairments, infection, pain, ringing in ears, and

excessive wax.

Musculoskeletal: Denies joint pain, neck pain,

and back problems. Denies deformities, joint

stuffiness, muscle cramps, muscle stiffness,

paralysis, weakness, and foot pain.

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Pediatric SOAP Note

Nose/Mouth/Throat: Reports congestion,

discharge, and runny nose. Denies frequent

colds, hay fever, infections, nasal obstruction,

nose bleeds, and sinus infections.

Neurological: Denies syncope, paralysis, and

weakness.

Genitourinary/Gynecological: Denies

awakening to urinate and bed wetting. Denies

blood in urine, burning, difficulties urinating.

Denies flank pain, increase in frequency,

incontinence, and pain. Denies starting a

menstrual cycle. Denies lesions and itching.

Heme/Lymph/Endo: Denies anxiety, sleeping

difficulties. Patient denies suicidal ideation

Developmental Problems: Patient and father

deny developmental difficulties.

Behavioral Status/Psychiatric: Denies behavior

issues, night sweats, and mood disorders.

OBJECTIVE

(Growth chart to include height/weight/head circumference plotted & noting percentiles; Please

attach these charts at the end of your SOAP note; include pertinent positives & negatives)

Weight: 153 pounds BMI: 33.11 Temp: 97.9 F BP: 106/74

Height: 59.1 Inches Pulse: 102 Respirations: 22

General Appearance & parent‐child interaction: A.D is a well-developed 10-year-old female.

Answers all questions appropriately. Patient is alert and oriented to person, place, and time.

Skin: Warm, dry, and intact. Capillary refill <3 seconds. Nails are smooth, color in correlation with

patient, pink bed of nails. All 10 digits noted. No cracking, or cyanosis noted. No clubbing noted.

Skin turgor elastic. No signs of dehydration noted. Hair is well distributed, brown, and thick.

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Pediatric SOAP Note

Head: Head is normocephalic. Symmetrical. No lesions or masses noted. Scalp is intact, no lesions or

nits noted. No craniofacial deformities noted. Hair is thick and soft, no signs of breakage noted.

Eyes: PEERLA intact. EMO intact. Conjunctiva is pink, no drainage noted, no palpebral edema noted.

Sclera is white, no drainage noted. Cornea intact. Eyelids pink, skin colored, no lessons or masses

noted. Eye brows are brown in color, thick, and evenly distributed.

Ears: Left tympanic membrane appears red and bulging. Right tympanic membrane is pearly grey,

slightly bulging. Light reflex present. No perforations of tympanic membranes noted.

Nose: Nasal drainage is clear, small amount. No pain upon palpation of sinuses. Septum is midline, no

deviation noted. Nares are patent, slight congestion noted. Turbinate erythematous bilaterally.

Throat/Mouth: Oral mucosa is pink, intact, moist. No bleeding noted. Routine dental screenings

performed every 6 months. Oral hygiene intact. No deformities or malformations noted on hard and

soft palate. Deciduous teeth intact. Top upper left molar coming through. Posterior pharynx

erythematous, no exudate noted. Tongue is midline. Tonsils erythematous, inflamed.

Neck: Full range of motion noted. No stiffness or difficulties noted. Thyroid moveable, no

enlargement noted. Trachea midline. Lymph noted palpable, no tenderness upon palpation.

Cardiovascular: Rate and rhythm regular. No murmur or gallops noted. S1 and S2 noted. Pulses +2

bilaterally. PMI left 2nd intercostal space, nondisplaced. No edema noted.

Respiratory: Mild expiratory wheezing bilateral lower lobes. Bilateral upper lobes clear. Regular rate

and rhythm. Chest expansion equal and symmetrical. Work of breathing as ease.

Gastrointestinal: Round, soft, non-distended. Bowel sounds presents LUQ, RUQ, LLQ, and RLQ.

No hepatomegaly.

Breast: Small breast buds noted. No masses, lesions, tenderness, or discharged noted. No dimpling or

discoloration of skin noted.

Genitourinary: No CVA tenders. Tanner stage II.

Musculoskeletal: ROM intact, no difficulties. Ambulates steady, no wobbling or leaning.

Neurological: AAOx4. Calm. Cooperative. Spine midline, no difficulties with ROM. Posture erect.

Behavioral/Psychiatric: Alert and oriented. Hair well groomed. Calm during interview, able to sit still

and quietly.

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Pediatric SOAP Note

Pediatric/Adolescent Assessment Tools: HEADSS-

H- Home- Lives at home with mother and father. Never home alone.

E-Education- Currently in the 4th grade. Able to read and write appropriately.

A-Activities- No sports at this time. Rides bike with helmet around neighborhood with parents.

D-Drugs- No illicit drug usage

S-Suicidality- Happy, calm. No suicidal ideations/attempts

S-Sex- No sexual contact. Patient knows to not allow others to look at genital area besides medical

professional and parents if there is a problem

Present Developmental: Child developmentally appropriate. Erikson’s stage- Industry vs. Inferiority.

Lab and/or Diagnostic Tests:

Influenza A swab- Negative

Influenza B swab- Negative

Rapid Strep test swab- Positive

DIAGNOSIS

Instructions:

Primary Diagnosis: Streptococcal Pharyngitis J02.0

This is an infection caused by group A Streptococcus. It is an infection of the oropharynx. The patient

presented with the common symptoms of sore throat and fatigue. On clinical examination the patient

presented with pharyngeal erythema without exudate. (CDC, 2018).

Differentials:

Acute Nasopharyngitis J00

Acute Nasopharyngitis is also the “common cold.” This is a viral infection that affects the upper

respiratory tract. The patient is a school aged child which increases her risk for the development of the

common cold. The patient presents with common signs and symptoms of such as, cough, sore throat,

congestion, and fatigue. The patient presents with a clear nasal discharge which can also be associated Revised 5/9/18; 8/9/18; 10/29/18;10/22/19

Pediatric SOAP Note

with the common cold. (Medical Joyworks, LLC, 2019).

Otitis Media, Left Ear H66.92

Otitis Media is the infection or inflammation of the middle ear. This is typically associated with a cold,

sore, throat, or respiratory infection. Currently the patient is positive for strep throat. (John Hopkins

University, 2019).

Final/Primary Diagnosis (es): Streptococcal pharyngitis J02.0

PLAN:

Medication: Amoxicillin 500 mg 2 tablets by mouth twice a day for 10 days.

Pharmacological treatments: Amoxicillin 500 mg 2 tablets by mouth twice a day for 10 days. Patient

education to use over-the-counter medication, Tylenol. Children’s Tylenol liquid suspension 160

mg/5ml. Patient educated to use 4 teaspoons every 6 hours as needed for pain management. (Tylenol,

2019).

Non-Pharmacological treatments: Patient educated to use warm, salt water gargles for pain

management. Patient educated to use cough drops to help with cough and throat pain. Patient and

father educated about the use of hot tea, honey, and chicken noodle soup. Patient and father educated

that patient may return to school after 24 hours of starting Amoxicillin. Patient educated about the

importance of frequent handwashing and good handwashing techniques. The patient is educated to

maintain adequate hydration to help with healing process. Patient is also educated to about the use of

nasal saline rinses to help with nasal congestion.

Follow up: Recommended in 2 weeks. Patient and father educated to return to the office if symptoms

worsen.

Vaccinations: No vaccinations given at this visit.

(Stead,2019).

(American Association of Pediatrics, 2017).

Self-Evaluation of Interaction with patient/family during clinic visit: This sick visit went very well.

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Pediatric SOAP Note

The child and the father were cooperative and information. A trusting connection was established. I was

able to describe all procedures and assessment that I was performing and the reasons why. I feel as

though my weakness was asking majority of the questions to the patient’s father. I should have directed

my questions more towards the child.

References:

2 To 20 Years: Girls. 2019, https://www.cdc.gov/growthcharts/data/set1clinical/cj41l022.pdf.

“Clinical Practice.” Clinical Practice, 2017, https://brightfutures.aap.org/clinical-

practice/Pages/default.aspx.

“Group A Strep.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention,

1 Nov. 2018, https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html.

“Nasopharyngitis - Explain Medicine: Medical Joyworks.” Explain Medicine - Medical Joyworks, 2019,

https://www.medicaljoyworks.com/explain-medicine/catalog/Pulmonology/Nasopharyngitis.

“Otitis Media.” Johns Hopkins Medicine, 2019, https://www.hopkinsmedicine.org/health/conditions-and-

diseases/otitis-media.

Stead, Wendy. “Patient Education: Sore Throat in Adults (Beyond the Basics).” UpToDate, 2019,

https://www.uptodate.com/contents/sore-throat-in-adults-beyond-the-basics/print.

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Pediatric SOAP Note

Revised 5/9/18; 8/9/18; 10/29/18;10/22/19

Pediatric SOAP Note

Revised 5/9/18; 8/9/18; 10/29/18;10/22/19