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PEDIATRIC FILLABLE SOAP NOTE TEMPLATEPEDIATRIC FILLABLE SOAP NOTE TEMPLATEPEDIATRIC FILLABLE SOAP NOTE TEMPLATE
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STUDENT NAME: Amy Brown
Patient Initials: K.L. Date of Encounter: 02/21/ Sex: Female Age: 22 months DOB: 4/17/ Place of Birth: Cape Coral Florida
Historian: Mother Present Concerns/CC : “K.L. has had a cough, congestion, fever and wheezing x5 days”
- Child Profile: Child has met all milestones for 22 months:
2 | PEDIATRIC SOAP
Family History: Mother: 28, healthy Father: 30, Asthma Maternal Grandmother: 56, HTN Maternal Grandfather: 59, Deceased (MVA) Paternal Grandmother: 48, Breast Cancer Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)
General: shortness Mother states normally healthy; recent Cardiovascular:^ Mother^ denies^ any^ unusual cough, congestion and fever; immunizations are of breath with age appropriate activities. No recent current; normal sleep patterns; no history of complaints^ of^ chest pain congenital syndromes or chromosomal abnormalities Skin: Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or (^) Respiratory: Mother states patient has had a cough, irritation. Gastrointestinal: Negative for abdominal pain and Eyes: Mother states does not have drainage from nausea/vomiting. Mother denies any appetite loss, eyes. Mother denies any pain or itching to bilateral denies any known constipation, diarrhea, flatulence, heartburn. Last stated bowel movement was this Ears: Mother states this is the second episode of AOM; no history of OME; no evidence of tympanic membrane perforation; no evidence of otitis externa, cholesteatoma, otorrhea, otalgia, and mastoiditis; no ear deformities noted, no history of a foreign body in the ear; no signs of hearing loss Genitourinary/Gynecological: Mother denies any known discharge or complaints of vaginal pain. States she has been urinating normal, no difficulties. Nose/Mouth/Throat: Mother states he has had recent nose drainage but no bleeds, sinus congestion, post nasal drainage or Musculoskeletal: Denies any recent injury or fall. Denies any known deficits in age appropriate Breast: deferred Neurological: Mother denies any complaints of headache. Has noted no gait abnormalities or recent Heme/Lymph/Endo: Mother denies any increase bruising or history of anemia. Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time due to just not feeling good, she states. Psychiatry: Mother states no known history of depression and participates appropriately for age in all activities
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight: 12.5 kg Temp 102.0 BP deferred Height 78.74 cm Pulse 134 Resp 25 OBJECTIVE: Physical Examination reveals a well-nourished female, well developed for age. Temp: 102.0, HR 134, RR 25, O2 sat 99% on room air. No blood pressure measured. Weight: 12.5 kg General Appearance and parent - child interaction: Maternal/Child both appear well kept and are in clean clothing, interaction is normal, mother is very attentive to child needs. Skin General skin overview reveals no significant rash or other lesion HEENT Normocephalic, PERRL, Conjunctiva clear with no drainage noted. Tympanic membrane normal on right ear and bulging on left ear, no exudation noted in right but left with exudation in ear canal, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted. Cardiovascular regular rate, capillary refill < 3sec. No gallop or murmur noted. Respiratory Breath sounds with expiratory wheezing bilaterally. Equal chest rise and fall. Gastrointestinal Bowel sounds heard in all four quadrants. Soft, no tenderness or distention noted upon palpation.
Preschool Pediatric Symptom Checklist, helps with the child’s behavior analysis. According to the worksheet this child’s behavior for age is within normal limits. 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.
Rx for: Amoxicillin 250mg/5ml every 8 hours Education: Inform parents that child’s symptoms should improve within 24-48 hours Ear infections are common in children, they can cause ear, fever, and trouble hearing. Ear infections usually occur in children after they have a cold, the fluid in the middle ear collects behind the eardrum causing it to bulge. Symptoms include: ●Fever ●Pulling on the ear ●Being fussier or less active than usual ●Having no appetite and not eating as much ●Vomiting or diarrhea ●Doing surgery to place a small tube in your child's eardrum In some children with chronic ear infections hearing loss can occur and your child may need to have small tubes placed in the eardrum to help drain the fluid. (Up To Date, 2018) Follow-up appointment with detailed plan of f/u: Try to keep ears dry and contact provider if symptoms get worse or do not improve after 48 hours. Keep regular appt with provider, sooner if needed.
Reference American Academy of Pediatrics. (2018). Screening tools. Retrieved from https://www.aap.org/en-us/advocacy- and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx Charles Y. Hu. (2019, February 27). MedCalc: Interactive Growth Charts: Front Page. Retrieved from http://www.medcalc.com/growth/?fbclid=IwAR33JR9Z91rWZrWzp0Xvals3w0S4MT- 9ZzjmmHe2JpWNPt9sZUlUDleFS5Q Chiocca, E., RNC, MSN, CPNP. Advanced Pediatric Assessment, Second Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826161765/ Up To Date. (2018, March 1). Ear infections. Retrieved from https://www.uptodate.com/contents/ear- infections- otitis-media-in-children-the-basics?topicRef=1204&source=see_link
