Pediatric SOAP Note 3

Table of Contents

Pediatric SOAP Note
Pediatric SOAP Note
Historian: Patient and motherPresent Concerns/CC: “We are here for follow up on labs results after frequent episodes of nose bleeds”
Child Profile:Patient is a 2 years old toddler who lives with both parents and grandmother from his mother side. He attends daycare Monday –Friday from 8-5 and the rest of the time is cared at home by his parents and grandmother. He drinks 8 ounces of whole milk x 3 times daily and eats solid foods. He is described as a good eater, and his diet include rice, beans, meat and yogurt. He does not like vegetables or fruits but parents try to include them. Patient has met all his milestones on time. He knows most colors, speaks 4-5 words sentences and is able to count to 12. Patient is in the process of toilet training and only uses pamper at nighttime. Patient sleeps 8-9 hours at night and 2 hours nap during the day. Patient rides in the back seat of the car. All cabinets are locked at home and house has smoke alarms.
HPI: (must include all components)2 y/o male born at 39 weeks gestation via uncomplicated vaginal delivery. Seen in the office accompanied by mother for follow up appointment and labs results. Patient had been seen 1week ago due to complaints of frequent nose bleeds. Last episode 1 weeks ago while in office in the presence of the doctor. Bleeding is usually unilateral but can be present in any nostril. Bleeding is usually of short duration and can be easily controlled with finger pressure. Mother denies bruises, easily bleeding, teeth bleeding or melena. Labs ordered showed an unremarkable complete blood count with only abnormal elevation of PT at 50.
PMHX:Allergies:  NKA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: NoneImmunizations: Up to date
Family HistoryMother is 28 years old and does not have a past medical historyFather is 36 years old and is healthy. However, he does report similar episodes of nose bleeds since he was a child. He was told it was nose dryness and was never diagnosed with any other diseaseMaternal grandmother suffers has GERD.Maternal grandfather suffers from Hypertension.Paternal grandmother has HypertensionPaternal grandfather has hypertension and suffered a TIA 3 years ago but is stable.History of bleeding disorder of his maternal uncle
Social History Patient lives with both parents and maternal grandmother in a rented house. Both parents are accounting and they are initiated their own office. He goes to daycare since he was 1 year and 6-month-old. Mother reports no guns at home, and they have smoke and CO2 alarms at home. Patient is an only child. He wears helmets for safety when riding bikes. Both parents are highly involved in his care.
GeneralDenies weakness, fever, fatigue, night sweats or malaiseCardiovascularDenies abnormal heart beats, murmurs, or chest trauma
SkinDenies rash, hives, urticarial, bruises or lesionsRespiratoryNegative for coughing up blood, respiratory distress or increased respirations
EyesDenies eye redness or dischargeGastrointestinalDenies blood in the stool, nausea, vomiting or anorexia 
EarsDenies ear tugging or dischargeGenitourinary/GynecologicalDenies cloudy urine or dysuria 
Nose/Mouth/ThroatMother reports several episodes of epistaxis.Negative for nasal congestion, mouth sores or dysphagiaMusculoskeletalDenies limitation of ROM or joint deformities
BreastNot examinedNeurologicalDenies epilepsy, syncope, hyperactivity or loss of consciousness
Heme/Lymph/EndoDenies anemia, unusual bruising, recent blood transfusions, enlarged lymph nodes, increased thirst. Positive for nose bleedsPsychiatricDenies sleep problems, anxiety or depression
Weight       35 lbsTemp 98.3BP 106/67
Height91.44 cmPulse 86Resp/ 18
General Appearance and parent‐child interactionHealthy appearing toddler, sitting on his mother’s lap with positive interaction with mother
SkinNormal skin turgor, with warm and intact skin. Capillary refill 2 seconds
HEENTNormocepahlic head with even hair distribution. Pupils PERRLA. EOMs intact. Tympanic membranes pink. Patent nasal nares. Septum midline. No obstruction or foreign body observed. Mouth with all teeth and molars without carries. No JVD. Neck supple and with full ROOM..
CardiovascularHeart rate and sounds with normal findings. No cyanosis, clubbing or edema. S1 and S2 present.
RespiratoryBilateral lung fields clear. Effortless respirations and chest wall expansion. No wheezing, crackles or Ronchi
GastrointestinalRound abdomen without rebound tenderness. BS active x 4.
BreastNot examined
GenitourinaryNormal external genitalia. Tenner stage 1
MusculoskeletalFull head control and normal spine curvature.
NeurologicalReflexes 2 + throughout. Moro reflex not present. Romberg test negative.
PsychiatricPlayful toddler with positive interaction with mother and healthcare provider. No indications of abuse.
In-house Lab Tests – document tests (results or pending)CBC: Unremarkable except for PT of 50
. Differential diagnosis-1. Von Willebrand Disease (D68.0): This is an inherit condition that produces a deficient clotting protein. Signs and symptoms of the disease include bleeding tendencies such as easy bruising, nosebleeds, heavy menstrual periods in females and other (SMITH, 2017). In this case frequent nose bleeds and the family history suggests this diagnosis.1. Mild hemophilia A (D68.311): This condition is also characterized by bleeding tendencies and is also an inherited autosomal disease (Karaman et al., 2015).1. Coagulation defect, unspecified (D68.9): Coagulation defects can be caused by genetics or by conditions such as vitamin K deficiency or liver problems (Karaman et al., 2015). Because this patient exhibits mild symptoms it’s important to include a more general differential diagnosis to determine the cause of the symptoms.Primary Diagnosis:. Von Willebrand Disease D68.0
PLAN including education
· Referral issued to hematologist to be seen as soon as possibleEducation· Educated about diagnosis. This condition affects primarily boys and although sometimes is asymptomatic typical presentation includes bleeding from mucosa and labs showing elevated PT (SMITH, 2017).· Explain that having this condition predispose the patient to bleeding that can be harder to control. It’s important to wear a medical alert bracelet and inform all healthcare providers of this diagnosis prior to any surgical or dental procedures· Hematologist must be seen for further testing to determine specific types of the disease and for recommendation of appropriate medical treatment if needed· When experiencing a nose bleed tilt head slightly forward and provide pressure to the nostril. If bleeding is not controlled seek emergency treatment· Use helmets and protective equipment to avoid injuries that can produce bleeding.· Use a soft toothbrush to avoid gum bleedings References:Karaman, K., Akbayram, S., Garipardıç, M., & Öner, A. F. (2015). Diagnostic evaluation of our patients with hemophilia A: 17-year experience. Turkish Pediatrics Archive / Turk Pediatri Arsivi50(2), 96-101. doi:10.5152/tpa.2015.2516SMITH, L. J. (2017). Laboratory Diagnosis of von Willebrand Disease. Clinical Laboratory Science30(2), 65-74.
Pediatric SOAP Note
Historian: Patient and her motherPresent Concerns/CC: “My throat is being hurting for the last 3 days and I start having fever since last night”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)9 years old male A+ student. He has met all his milestone timely. He actively engaged in sports, currently playing basketball in the school team. He likes to eat fast food but his mother reports that he tried to reinforce him to eat balanced meals including fruits and vegetables every day as well as maintaining an adequate hydration status throughout the day by drinking water and Gatorade while practice basketball. Patient sleeps an estimate of 8 to 9 hours at night. Denies problems falling or staying asleep. No indications of bullying at school. He wears seatbelt always. Mother reports smoke alarm at home denies guns possession at home.
HPI: (must include all components)Patient with no significant PMH. Presented to the clinic c/o cough, sore throat for 3 days and fever since last night. He stated when he swallows, the pain is worse and only feels some relief with cold drinks. Mother stated that his max Temp was 1011. last night and she gave him Ibuprofen OTC for the fever. Pain is described as feeling a raw throat.
Medications: (List with reason for med)Ibuprofen OTC 12.5 ml every 4 hours as needed for fever.
PMHX:Allergies: NKAMedication Intolerances: NoneChronic Illnesses/ traumas: noneHospitalizations/Surgeries: oneImmunizations: All immunizations up to date, except for FLU vaccine for this year.
Family History ( Please identify all immediate family)Mother and father are alive and healthy.Maternal grandfather died at 60 years old from a car accident. Maternal grandmother alive suffering from generalized OA.Paternal Grandfather alive suffering from BPH and TIA. Paternal Grandmother alive suffering from HTN.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety statusPatient is only child who lives with his parents in peaceful house environment. He is described by his mother as an excellent son and student always willing to help in the house. Both parents are professionals who work full time. Patient can watch TV for 1 hours a day. Mother denies exposure to alcohol, drugs, or smoking. Safety at home with smoke and CO2 detectors, alarm, and cameras.
GeneralDenies malaise, weakness, or night sweats. Positive for fever up to 101 F and decreased appetiteCardiovascularDenies chest pain, heart murmurs or leg swelling
SkinDenis petechiae, bruises, wounds, or ecchymosisRespiratoryReport cough. Denies hemoptysis, difficulty breathing or SOB
Pediatric SOAP Note
EyesDenies eye pain, discharge, or visual problemsGastrointestinalDenies nausea, vomiting, constipation, or diarrhea, pyrosis, or epigastric pain. Report anorexia
EarsReport ear pressure. Denies vertigo or tinnitusGenitourinary/GynecologicalDenies cloudy urine, urgency, or incontinence
Nose/Mouth/ThroatReport sore throat and difficulty swallowing. Denies for hoarseness, nasal congestion, or nose bleedsMusculoskeletalDenies joint pain or stiffness
BreastNot assessedNeurologicalDenies headaches, numbness, tingling or syncope
Heme/Lymph/EndoDenies fatigue, anemia, cold/heat intolerance or enlarged lymph nodesPsychiatricDenies depression, insomnia, or nightmares
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight80 lbs (59th percentile)Temp99.1BP107/65
Height4’10” (19th percentile)Pulse76Resp18
General Appearance and parent‐child interaction:Healthy appearing child in NAD with normal ambulation and interaction with mother and healthcare provider
SkinSkin is warm, dry, clean, and intact. No rashes or lesions noted.
HEENTHead is non-traumatic. EOMs intact. Pupils PERRLA. Neck is supple without JVD. Tympanic membranes clear of fluid without redness. Nose with patent nares and midline septum. Throat is very erythematous with inflamed uvula, tonsils, and pharynx. No lesions or exudates present. Neck supple with full ROM.
CardiovascularNormal heart rate and sounds. Pedal pulses 2+ bilaterally. No cyanosis, clubbing or edema of the lower extremities
RespiratoryBreathing effort within normal limits. Lungs clear to auscultation bilaterally
GastrointestinalBowel sounds active x 4 quadrants. No rigidity or guarding.
BreastNot assessed
GenitourinaryNo bladder distention or CVA tenderness
MusculoskeletalErect posture. Stable joints without pain or tenderness to palpation
NeurologicalSpeech clear. Balance stable; gait normal.
PsychiatricNormal mood, affect and interaction. AAO x3. No signs of suicidal intentions
In-house Lab Tests – document tests (results or pending)Rapid strep throat group A: positive
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationaleFor adolescents (HEADSSSVG Assessment)HEADSSSVG was conducted and no evidence of depression was found. Patient lives with parents at home. Reports having a happy life. No concerns currently.
. Differential diagnosis-. Streptococcal pharyngitis (J02.0): According to the Columbian Electronic Encyclopedia (2017), this condition mainly occurs in children and typical signs and symptoms include fever and sore throat. Acute tonsillitis (J03.90): Tonsillitis is an inflammation of the tonsils. It can be caused by viral or bacterial infections (Gahleitner et al., 2016). It typically causes throat pain, difficulty swallowing and loss of voice.. Viral pharyngitis (J02.9): When no bacteria is found, it’s referred as viral pharyngitis. This can cause all the same symptoms including sore throat, dysphagia, fever and rednessPrimary Diagnosis:. J02.0: Streptococcal pharyngitis.Plan including education· Bicillin L-A 1,200,000 units/2ml per syringe. Administer 1.2ml IM in the office. This is indicated for treatment of Group A streptococcal infection (Columbia Electronic Encyclopedia, 2017).· F/U in the office in 72 hours if no improvementEducation· Call 911 if patient developed symptoms of difficulty breathing, lip cyanosis or inability to open the mouth. This can be indicative of serious life-threatening condition or allergic reaction and emergent treatment is needed.· Increase fluid intake. This will help fight the fever the infection while preventing dehydration· Use cold compresses to decrease fever.· Use light clothing when fever is high to allow the body to cool down· Wait 24 hours before returning to school· Call office if symptoms do not improve within 48 hours.References:Gahleitner, C., Hofauer, B., Stark, T., & Knopf, A. (2016). Predisposing factors and management ofcomplications in acute tonsillitis. Acta Oto-Laryngologica136(9), 964-968.doi:10.3109/00016489.2016.1170202Sore throat, streptococcal. (2017). Columbia Electronic Encyclopedia, 6th Edition, 1.

*ALL references must be Evidence Based (EB)

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