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PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME: DATE OF ASSIGNMENT: 10/22/
Patient Initials: B.L. Date of Encounter: 10/15/
Sex: Female Age/DOB/Place of Birth: 10; 4/3/09; Bloomington,
Indiana
SUBJECTIVE Historian: mother and daughter Present Concerns/CC : Patient mother states she brought her daughter in today regarding to the rash developed over both of her arms and itchiness that her daughter complaining of. 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 performing appropriate adl, patient is safe and wears a seatbelt, goes to afterschool care Monday through Friday, on the weekends she participates in theater classes. HPI: (must include all components - OLD CARTS) Rash presenting on bilateral arms starting 2 days ago. Patient complains of itchiness as well as flaky skin. Patient mother state gave bendryl. Patient recently used scented shower gel. Mother did state that she recently switched to a new detergent. Medications : (List with reason for meds) n/a
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PMH:
Allergies: No known allergies Medication Intolerances: none Chronic Illnesses/Major traumas: none Hospitalizations/Surgeries: Ear tube 5/ Immunizations: Patient has received Heb B X 3, RV X 2, DTAP X 5, HIB X 3, PCV13 X4, IPV X4, MMR X 2, and VAR X 2
1 | P E D I A T R I C S O A P N O T E
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OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight 102 Temp 98.9 BP 118/ Height 5f 2 in Pulse 82 Resp 16 OBJECTIVE (Physical Examination) General Appearance and parent - child interaction Patient looks well has arms crossed trying hide arms. Patient A&O X 3, appropriate responses, cooperative and appears without distress. Skin Skin is warm. Patients skin presents dry and rash with reddened skin. Also some scaly patches in the upper arms. HEENT Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. No conjunctival or sclera injections. Ears: Canals have clear bilateral TM pearly gray with + light reflex. Nares patent and mucosa pink; no septal deviation. Neck: supple. Full ROM. No Bruits Oral mucosa is pink and most Pharynx: swallows w/o difficulty, no erythema; Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refill two seconds. Pulses are 3+ throughout. No edema on lower extremities Respiratory Symmetric chest wall expansion. Respirations regular and easy. Breath sounds clear, no rales, wheezes, or rhonchi. Gastrointestinal Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness. Breast deferred Genitourinary deferred
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Musculoskeletal Flexed forward at 15º, walked normal with a wide based stance. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis. Attempts at ROM did not produce pain Straight leg raises (SLR) negative. No noted
3) Dermatitis L30.
2) Pruritus L29.
1) Rash and other nonspecific skin eruption R
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.
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Neurological Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 for all sides. Gait stable. Reflexes 2 + Psychiatric Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time. Maintains eye contact, speech is soft and clear and normal rate. Answers questions appropriately In-house Lab Tests – document tests (results or pending) Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
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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 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 Non-medication treatments Follow-up appointment with detailed plan of f/u
Discuss with mother of patient to change what she is washing the clothes in to a downy which is found to be more sensi
Patient can use moisturizer which can help the dryness of the skin. If the rash is still there in a week, we will refer to der
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*ALL references must be Evidence Based (EB) Mayo Clinic. (2019). Dermatitis. Retrieved from https://www.mayoclinic.org/diseases- conditions/dermatitis-eczema/symptoms- causes/syc-20352380.
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