week 5 pediatric soap note

Student name:

Course:

Patient name (initials only): J.S

Date:07/25/2025 Time:10:15 AM

Ethnicity: Hispanic

Age: 14 Sex: Male

SUBJECTIVE

CC: "I've had a sore throat for the past three days."

HPI: J.S. is a 14-year-old Hispanic male who presents with a complaint of sore throat for the past 3 days. He describes the pain as scratchy and mild to moderate in intensity, rating it around 4/10. The onset was gradual, and the discomfort is constant throughout the day, slightly worsening when swallowing. He denies any fever, cough, nasal congestion, shortness of breath, or recent exposure to sick contacts. He has not taken any medication for the sore throat yet. No recent travel or new foods reported. He reports maintaining a regular diet with slightly decreased appetite due to throat discomfort. Physical activity is normal for age, and he remains active at school and with sports. Elimination patterns are normal with no reported constipation or diarrhea. Sleep has been slightly disturbed due to the throat discomfort, but he is still getting approximately 7-8 hours per night. No associated ear pain, rash, or other systemic symptoms noted. Parents have been encouraging him to drink fluids, and he has started gargling with salt water today as advised by a relative.

O- Sore throat started 3 days ago

L- throat pain

D- The sore throat is constant

C- Feels scratchy

A swallowing makes it more painful

R. Tylenol and warm drinks like tea helps

T- Tylenol – time last dose and what dose was taken?

Medications: None currently; no OTC or prescription medications taken for sore throat.

Past medical history: Unremarkable; no history of chronic illnesses or recurrent infections.

Allergies: No known drug or food allergies (NKDA).

Birth hx: (use only on well child visits): N/A

Immunizations: Up to date per parent report and clinic records.

Hospitalizations:None

Past surgical history: None

Social history: Lives at home with both parents and two siblings. Attends school regularly, active in sports, denies exposure to tobacco or secondhand smoke.

Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes): N/A

FAMILY HISTORY

Mother: Alive, 40 y/o, healthy, no chronic medical conditions.

MGM: Type 2 diabetes mellitus diagnosed in her 60s, living.

MGF: Hypertension; died of myocardial infarction at age 72.

Father: Alive, 42 y/o, seasonal allergic rhinitis; otherwise healthy.

PGM: Alive, 68 y/o, hypothyroidism (on levothyroxine).

PGF: Coronary artery disease with stent placement at 65 y/o; still living and stable.

REVIEW OF SYSTEMS

General: Denies fever, chills, weight loss, or fatigue.

Cardiovascular: Denies chest pain, palpitations, or syncope.

Skin: No rashes, lesions, or itching.

Respiratory: Denies cough, shortness of breath, or wheezing.

Eyes: No redness, discharge, or visual changes.

Gastrointestinal: Denies nausea, vomiting, diarrhea, or abdominal pain; appetite slightly decreased due to throat discomfort.

Ears: Denies ear pain, discharge, or hearing loss.

Genitourinary/Gynecological: N/A

Nose/Mouth/Throat: Reports sore throat x3 days; denies nasal congestion, runny nose, or mouth sores.

Musculoskeletal: No joint pain, muscle aches, or swelling.

Breast: : Not Applicable Heme/Lymph/Endo: Denies bruising, bleeding, or heat/cold intolerance.

Neurological: Denies headache, dizziness, or weakness.

Psychiatry: N/A

OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)

Weight: 110 lbs Height: 5'4" BMI: 18.9 BP: 110/70 mmHg Temp: 98.6°F (oral) Pulse: 84 bpm Resp: 18 bpm

(Insert plotted growth chart below on all well child soap notes)

General appearance: Alert, cooperative, well-nourished, no acute distress.

Skin: Intact to thorax, bilateral upper and lower extremities; no bruising, ecchymosis, or skin tears noted.

HEENT:

Head: Normocephalic, atraumatic, no scalp lesions; fontanelles closed.

Eyes: PERRLA, EOMI, conjunctivae clear, sclerae white, no discharge or redness. Specify right/left or bilateral

Ears: External ears normal- We do not use normal- need to document specific external ear exam- Need to use your Peds PE book and review

TMs intact bilaterally- missing color of TM- pearly gray??

with visible cones of light at 5 o'clock (right) and 7 o'clock (left), no erythema or effusion.

Nose: Nares patent bilaterally, no discharge or turbinate swelling.

Sinuses: Non-tender to palpation over frontal and maxillary sinuses.

Mouth: Buccal mucosa moist and pink; dentition appropriate for age with no obvious caries.

Throat: Erythematous pharynx; no exudate noted.

Tonsils: +2 bilaterally, no exudate.

Neck: posterior auricular, preauricular, superficial cervical, posterior cervical, supraclavicular, deep cervical, submental and deep cervical lymph nodes non-tender, no swelling noted

Cardiovascular: S1, S2 normal; no murmurs, rubs, or gallops.

Respiratory: Clear to auscultation bilaterally in upper and lower lobes, anteriorly, posteriorly, and laterally; no wheezes, rales, or rhonchi.

Gastrointestinal: Abdomen soft, non-distended, non-tender; bowel sounds present in all quadrants.

Need to document BS in all 4 quadrants

Genitourinary: Deferred; no complaints.

Musculoskeletal: Full range of motion in all extremities; strength 5/5 bilaterally upper and lower extremities; no joint swelling or tenderness.

Neurological: N/A

Psychiatric: N/A

Labs performed in office the day of visit: Throat culture

Centor criteria 3 points

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)

Differential diagnoses:

1. Acute Pharyngitis, Unspecified (J02.9) – Final Diagnosis

Reference: ICD-10-CM J02.9

Rationale: The patient presents with a sore throat lasting 3 days, erythematous pharynx, and +2 tonsillar enlargement bilaterally, without exudate. There are no associated symptoms such as fever, cough, nasal congestion, or systemic illness. Lung sounds are clear, and no lymphadenopathy is noted. This presentation is consistent with uncomplicated acute pharyngitis, most likely viral in etiology. This diagnosis is supported by the absence of exudate, high fever, tender anterior cervical lymphadenopathy, or other Centor criteria that would raise concern for bacterial pharyngitis (Pellegrino et al., 2023). The mild presentation and normal vitals further support a benign, self-limited course.

2. Streptococcal Pharyngitis (J02.0)

Reference: ICD-10-CM J02.0

Rationale: Streptococcal pharyngitis is a common concern in adolescents with sore throat (Ashurst & Edgerley-Gibb, 2023). However, this diagnosis was ruled out due to the absence of hallmark features such as fever >100.4°F, anterior cervical lymphadenopathy, tonsillar exudate, and absence of cough (Centor criteria). Additionally, there is no history of recent known exposure to strep or high community prevalence prompting testing. A rapid strep test was not indicated based on current symptoms, and the throat appears only mildly inflamed with +1 tonsils. Thus, bacterial pharyngitis is considered less likely.

3. Infectious Mononucleosis (B27.90)

Reference: ICD-10-CM B27.90

Rationale: Infectious mononucleosis commonly presents in adolescents with sore throat, fatigue, and lymphadenopathy (Leung et al., 2023). It often includes fever and significant tonsillar hypertrophy with exudate. This diagnosis is ruled out due to the absence of systemic symptoms like extreme fatigue, hepatosplenomegaly, or posterior cervical lymphadenopathy. The patient also denies fever or malaise, and the throat exam does not show the exudative pharyngitis typically associated with EBV.

Final Diagnosis:

Acute Pharyngitis, Unspecified (J02.9)

The diagnosis was made based on the patient’s localized sore throat, absence of bacterial or viral red flags requiring further testing, and normal physical exam aside from mild throat erythema and tonsillar enlargement. Conservative supportive management is appropriate (Pellegrino et al., 2023).

Plan/therapeutics/diagnostics;

Supportive care for acute viral pharyngitis.

Gargle with warm salt water (½ tsp salt in 8 oz water) 2–3 times daily.

Acetaminophen 325 mg PO every 4–6 hrs PRN sore throat or pain (max 3,000 mg/day).

Ibuprofen 200 mg PO every 6–8 hrs PRN pain or fever (max 1,200 mg/day).

No antibiotics indicated at this time.

Education provided:

Encourage hydration with water, warm broths, and herbal teas. Avoid citrus juices that may irritate throat.

Diet should include soft, bland foods: applesauce, mashed potatoes, soup, yogurt, scrambled eggs. Avoid spicy or crunchy foods.

Educated on appropriate use of Tylenol and Motrin; common side effects include GI upset or allergic reaction, seek care if rash or difficulty breathing occurs.

Symptoms should improve within 5–7 days. Call office if sore throat worsens, fever >101°F develops, difficulty swallowing or breathing occurs.

If symptoms persist >7 days or worsen, follow up in office.

CPT Code: 99213 (Problem-focused visit)

Health Maintenance:

Annual physical exam in 2 months

Dental visit

Blood pressure assessment

Depression screening

Anticipatory guidance (well child visit only): Not applicable