soap 7

Patient Initials: S.L.

Date of Encounter: 06/10/2020

Sex: Male

Age/DOB/Place of Birth: 14yo, DOB: 07/28/2005, Miami, FL

SUBJECTIVE

Historian: Patient S.L.

Present Concerns/CC: “I have a big pimple on my butt”

Reason given by the patient for seeking medical care “in quotes”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;

Sports/physical activity; Developmental Hx)

Patient is sexually inactive, starts high school in the Fall. He spends a lot of his time playing video games with his friends on Xbox. He also plays football outside with his neighborhood friends at least 2 times. The coronavirus pandemic has him restricted from going out with his friends, but he would do this before the pandemic.

HPI: (must include all components - OLD CARTS)

The patient was playing football outside when he fell on his rear and scraped through his clothing. He continued to play for at least a few more hours before returning home to clean himself. After several days he noticed something painful when sitting down and checked the mirror to see a big red pimple on his butt. He has had it for around 1 week before coming to see his PCP. He states the pain when sitting is a 6 out of 10. It is localized to this area and has not spread elsewhere.

Medications: (List with reason for meds)

Patient not currently taking any medication

PMH:

Allergies: None

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

None

Hospitalizations/Surgeries:

None

Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine.

Family History (please identify all immediate family)

Mother: 36 years old, no current health problems

Father: 34 years old, no current health problems

2 brothers (10 y/o, and 5 y/o)

Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)

Will start high school soon. Lives with his parents and 2 brothers in a house. Has not smoked tobacco products, drank alcohol, or smoked marijuana products. Patient states feeling safe at home and in school.

Review of Systems (ROS)

General

Positive painful pimple on his buttocks. Denies fever, nausea, or chills

Cardiovascular

Denies chest pain, pressure, palpitations

Skin

Positive for painful pimple on his buttocks, no lesions elsewhere.

Respiratory

Denies shortness of breath, denies cough, denies difficulty breathing

Eyes

Denies blurred vision, denies visual loss, denies double vision

Gastrointestinal

Denies nausea or abdominal pain. Denies diarrhea. Denies vomiting

Ears

Denies hearing loss, pain, or drainage

Genitourinary/Gynecological

Denies painful urination, denies increased frequency

Nose/Mouth/Throat

Denies throat pain. Denies difficulty swallowing Denies congestion, denies discharge, denies mouth pain.

Musculoskeletal

Denies pain, denies limited range of movement.

Breast

N/A

Neurological

Denies numbing or loss of sensation, denies headache or dizziness, denies syncope, paralysis, or ataxia.

Heme/Lymph/Endo

Denies anemia, bleeding or bruising, denies enlarged nodes. Denies change in temperature sensitivity.

Psychiatric

Denies anxiety, or depression. Denies mood swings, denies insomnia.

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

Attach growth chart

Weight 142 lbs.

Around 87th percentile

Temp 97.9 F

BP 110/69 mm/hg

Height 69 inches, 5’9”

Around 91st percentile

BMI: 21

Growth chart at bottom of SOAP Note

Pulse 65 bpm

Resp 15/min

OBJECTIVE (Physical Examination)

General Appearance and parent-child interaction

Patient looks well groomed, and in no obvious distress. He came with his mother today and their interaction seems normal, there are no signs of abuse or fear.

Skin

Large skin abscess on his right buttock (3 cm). Erythematous, warm, skin around red and swollen. Pus filled.

Skin around the nose, eyes, and mouth is normal for age. Slight presence of comedones, and papulopustules. Age appropriate. No cyanosis, clubbing or bruises.

HEENT

Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TM’s pearly grey with positive light reflex. Neck: supple, full ROM. Mouth/Throat: Throat is visibly pink, and non-inflammatory.

Cardiovascular

S1, S2 heard, normal rate, normal rhythm, 2 sec capillary refills, no murmurs, no gallops, no palpation, no edema.

Respiratory

Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no Ronchi, No wheezing.

Gastrointestinal

Soft, and non-tender to palpation. No masses. Bowel sounds present in all four quadrants, no splenomegaly, no hepatomegaly. No rebound, no guarding. No visible signs of dehydration.

Breast

N/A

Genitourinary

External genitalia assessment deferred.

Musculoskeletal

Normal gait and ROM. No rigidity, no deformities. No atrophy

Neurological

Normal tone, no local findings

Psychiatric

No depression or anxiety, no insomnia.

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

None

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

Tanner Stage 3. The child is asked about pubic hairs, and states that he has some but not that many. His buttocks have scant hair growth on them. (Emmanuel & Bokor, 2019).

HEADSS Assessment (Katzenllenbogen, n.d.)

H- Lives with his parents in Miami, FL. Has lived at current house for 2 years. Has no pets. The patient feels safe at home and in his neighborhood. There are no weapons at home

E- Will start high school in the fall. Did well and got good grades in middle school. Wants to play for a high school football team.

A- Plays video games mostly, but also has several hours of physical activity weekly by playing football with his friends.

D- Patients mother states that he has never been in contact with or ever experienced being around anyone with drugs of any kind.

S- Patient has never had a sexual partner. He identifies as straight, having an attraction for the opposite sex.

S- Denies feelings of suicide or depression.

ASSESSMENT (Diagnosis – 3 Differentials and Primary)

· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives

· Primary diagnosis

· Is #1 on list of differentials

· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.

1) Furuncle of buttock (L02.32) This is objectively what the patient has and was found during the physical examination.

2) Other specified local infections of the skin and subcutaneous tissue (L08.8) The most common causes of skin abscess infections in children are group A Streptococcus, and Staphylococcus aureus (Rayala & Morrell, 2017).

3) Methicillin resistant Staphylococcus aureus infection, unspecified site (A49.02) This diagnosis is not supported by any found evidence in this objective encounter, but the emergence of MRSA has been on the rise, and it may be possible for this to be a case.

PLAN including education

PLAN including education

· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

· Include EB rationale for all aspects of your treatment plan:

· Vaccines administered this visit

· Vaccine administration forms given

· Medication-amounts and mg/kg for medications

· Laboratory tests ordered

· Diagnostic tests ordered

· Patient education including preventive care and anticipatory guidance 9 Non-medication treatments Follow-up appointment with detailed plan of f/u

Treatment:

This abscess will be incised and drained in the clinic. We have the proper facilities and equipment to do so, including topical anesthetic and sterilized measures. After incision and drainage of the abscess, the wound will be treated with systemic antibiotic therapy in order to kill off any bacteria that remain, that may cause a future infection. Additionally, the patient should return to the office for 3 consecutive days for wound care management. After 3 days we can re-evaluate the wound to see if more care is required. For antibiotic therapy I recommend Bactrim (Trimethoprim and Sulfamethoxazole) 80mg/400mg. It should be taken every 12 hours for 10 days (Lin et.al., 2018). Trimethoprim and Sulfamethoxazole (TMP-SMX) is a first line treatment for uncomplicated skin abscess likely caused by a Staphylococcus aureus infection (Wang et.al., 2018). The patient is advised to rest and refrain from any physical activity or any contact sports until the treatment is concluded, and the wound has healed. He should drink plenty of liquids, and eat healthy, low fat foods. If any side effects occur, including fever, nausea, or diarrhea, please do not hesitate to come back to the clinic for evaluation. We will re-evaluate the course of treatment at every wound care session.

References

Emmanuel, M., & Bokor, B. R. (2019, May 13). Tanner Stages. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470280/

Katzenellenbogen, R. (n.d.). HEADSS: The "Review of Systems" for Adolescents. Retrieved May 3, 2020, from https://journalofethics.ama-assn.org/article/headss-review-systems-adolescents/2005-03

Lin, H. S., Lin, P. T., Tsai, Y. S., Wang, S. H., & Chi, C. C. (2018). Interventions for bacterial folliculitis and boils (furuncles and carbuncles). The Cochrane Database of Systematic Reviews, 2018(8)

Rayala, B. Z., & Morrell, D. S. (2017). Common Skin Conditions in Children: Skin Infections. FP Essentials, 453, 26-32.

Wang, W., Chen, W., Liu, Y., Siemieniuk, R. C., Martinez, J. D., Guyatt, G. H., & Sun, X. (2018). Antibiotics for uncomplicated skin abscesses: Systematic review and network meta-analysis. BMJ, 8.