SOAP NOTE

Name: AL

Date: 4/13/2018

Sex: Male

Age/DOB/Place of Birth/Case Number: 18 months-old/10-20-2016/Miami, Fl.

SUBJECTIVE

Historian: Child’s mum;

Present Concerns/CC: “My boy kept coughing even after being given ranitidine, don’t know if they are allergies or something else. On my way here, I felt him warm.”

Child Profile: Age-Appropriate Health Screening Activities: patient walks and runs on his own, despite being messy, he feeds himself using his hands, mother reports that baby use more his left hands than the right side. He holds utensils while pretending to sweep the floor or brushing his teeth.

HPI: 18 months old baby delivered by C-section at 33 weeks of gestation is presenting to the office with his mother with a chief complaint of a productive cough and reflux. As per mom” baby may have allergies due to episodes of heavy breathing with open mouth. During last visit, patient was prescribed with Ranitidine (15mg/ml) 1.75ml po bid x7 days for reflux symptoms. The previous dx was done by a clinic pediatrician at a neighboring clinic. It was with reflux. The kid has a slight fever and the cough changes his disposition and is present in sleep. He feeds himself using his hands, though must be closely monitored by the mother. He breaths using his mouth heavily as an effect of the cough. He occasionally suffers short breath and retractions. He has no history of a recent cold. Chronic Illnesses/Major traumas: GERD diagnostic 2 weeks ago

Medications: Ranitidine (15mg/ml) 1.75ml po bid x7 days. The mother is informed to administer the prescribed dosage for 7 days and report progress after the said period.

PMH:

Allergies: No allergies known

Medication Intolerances: None reported.

Immunizations: Fully immunized, last one given on 9/9/2016

Family History:

From the paternal side, grandmother suffered from Hypertension, Diabetes mellitus, gout and obesity. Additionally, mother reports suffering from bronchitis herself as a child. She is allergic to Penicillin

Social History

Both parents live at home with patient, mother denied any concern about safety hazards, no pet at home, they both Drugs free. Patient’s father work as an CPA accountant for a cruise line and the mother as Physical Therapist for a local skilled nursing facility. AL spends 5 days a week, from 8am to 5pm at daycare.

ROS

General

Mother denies any fatigue, weight change, not variation of energy level. Also no reports of night sweats, chills or fever, She denied any change in his appetite.

Cardiovascular

Denies any cardiovascular issues.

Skin

Denies bruising, rashes, skin discoloration or rashes reported. Also denies any changes on moles or lesions.

Respiratory

Report the child breathes using the mouth heavily. Denies any history of TB, pneumonia or hemoptysis.

Eyes:

Gastrointestinal:

Denies, constipation, N/V/D, hepatitis or black tarry stool. Reports reflux and some signs or throat pain or discomfort. Last bowel movement effective today. Nose/Mouth/Throat: Reflux episodes reported, mentions how the kid, sometimes shows discomfort on the throat. Mother denied any nose bleed or discharge, no dysphagia or obvious sinus problems.(Shown in the HPI)

Ears

Genitourinary/Gynecological:

Denies urinary concerns reported. Mother reports baby drink a lot of fluid

Nose/Mouth/Throat:

Report reflux episodes reported, mentions how the kid, sometimes shows discomfort on the throat. Mother denied any nose bleed or discharge, no dysphagia or obvious sinus problems.(Shown in the HPI)

Musculoskeletal:

Denies musculoskeletal concerns reported: no joint swelling, fracture history, stiffness or pain.

Breast

Denies lumps

Neurological:

Heme/Lymph/Endo:

Denies cold or heat intolerance. No reports of blood transfusion history, bruising, HIV status, swollen glands, night sweats, increased hunger or thirst.

Psychiatric: No psychiatric concerns reported

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight 27.2 lbs

Temp 100F

BP 85/51

Height 24”

Rate 88 beat/min

Height 24 in

General Appearance and parent‐child interaction:

Mother brings an alert 18 months-old male child, who at was clinging to his mother, but then was interacting and smiling. Child is well dress and clean.

Skin

Skin is clean and intact; warm and dry. No lesions or rashes noted.

HEENT

Head: normocephalic, atraumatic and without lesions; hair evenly distributed.

Eyes: PERRLA. No conjunctival or scleral injection.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized.

Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes.

Oral mucosa: pink and moist.

Pharynx: nonerythematous and without exudate. 8 (4 top, 4 bottom) front teeth in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

As noted in the HPI section, the child was observed with adequate expiratory wheezing to left and right upper lobes on auscultation. Accessory muscle use. Symmetric chest walls.

Gastrointestinal

Abdomen: Soft, non-distended, and non-tender. Bowel sounds active in all 4 quadrants, no hepatosplenomegaly. Mother reports last bowel movement effective today

Breast

No Breast Exam performed

Genitourinary

External genitalia exam postponed. Bladder is non-distended. No difficulties to urinate

Musculoskeletal

As child moved about the room unassisted. Child is full ROM in all 4 extremities. No clicks or rubbing to joints.

Neurological

Able to indicate pain with some clear words. Good balance while walking. No assistance to be transfer.

Psychiatric

Alert, responsive to social cues (waves hi and bye, smiles).

In-house Lab Tests – document tests (results or pending)

N/A

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

None Applied

Diagnosis

· A: Differential diagnosis with cited rationale (if applicable)

· Asthma (J45.909) see below.

· Medication-amounts and mg/kg for medications: Albuterol (1.25mg/3ml) 1 vial nebulizer q6h x 4 days (with one treatment at the clinic); Singular 4 mg po at bedtime x 6 months. The concentration of the medication is 4mol.

Follow Up:

▪ to follow up in one week from today to evaluate the outcomes of initial treatment-plan.

▪ If symptoms were to worsen despite the medication, inform the office and bring boy to closes ER room.