PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME:
DATE OF ASSIGNMENT: 05/11/2020
Patient Initials: J.T.
Date of Encounter: 05/06/2020
Sex: Male
Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL
SUBJECTIVE
Historian: Patient J.T.
Present Concerns/CC: My throat has been hurting recently
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, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes.
HPI: (must include all components – OLD CARTS)
Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while.
Medications: (List with reason for meds)
Patient not currently taking any medication
PMH:
Allergies: Dog hair, cat hair
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: 32 years old, no current health problems
Father: 34 years old, no current health problems
Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)
Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family.
Review of Systems (ROS)
General
Denies fevers, chills, nausea, and vomiting
Cardiovascular
Denies chest pain, pressure, palpitations
Skin
Denies lesions, itching, or redness.
Respiratory
Denies shortness of breath, denies cough, denies difficulty breathing
Eyes
Denies blurred vision, denies visual loss, denies double vision
Gastrointestinal
Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools.
Ears
Denies hearing loss, pain, or drainage
Genitourinary/Gynecological
Denies painful urination, denies increased frequency
Nose/Mouth/Throat
Positive for throat pain 3/10. Positive for some 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 98 lbs.
Around 73rd percentile
Temp 98.1 F
BP 113/78 bp
Height 61 inches, 51
Around 92nd percentile
BMI: 18.5
Growth chart at bottom of SOAP Note
Pulse 89 bpm
Resp 17 rr
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
Skin around the nose, eyes, and mouth is normal for age. No presence of comedones, or papulopustules. No cyanosis, clubbing or bruises.
HEENT
Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TMs pearly grey with positive light reflex. Neck: supple, full ROM. Mouth/Throat: Throat is visibly red, and inflammatory. No presence of blood detected. oral mucosa pink and moist, dental caries, gag reflex present.
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, tender to palpation. No masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding
Breast
N/A
Genitourinary
No CVA tenderness. 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)
Rapid strep antigen test- Negative for strep throat
Throat culture pending results
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
Tanner Stage 2. When asked, the patient states that he has begun to grow some pubic hair, and his voice has been cracking lately. This is characteristic of the early stages of puberty at Tanner stage 2. (Emmanuel & Bokor, 2019).
HEADSS Assessment (Katzenllenbogen, n.d.)
H- Lives with his parents in Miami, FL. Has lived at their 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- Goes to school at a local middle school. Taking online classes due to COVID-19 pandemic. The patient has good grades and feels safe at school. He is unsure of what life he wants to lead.
A- Plays videogames with his friends mostly. He goes out with his parents and brothers sometimes before the pandemic.
D- He states that he has never been in contact with or ever experienced being around anyone with drugs of any kind.
S- The patient states that he has never thought about or ever tried to commit suicide. He has never felt depressed.
S- The patient states that he has never had sex. He has never been sexually abused by anyone in his family or any strangers.
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) Acute pharyngitis, unspecified (J02.9) The most likely diagnosis is a sore throat. It can be caused by many things including colds, the flu, or bacterial streptococcus (Pharyngitis, n.d.). In this patients case, it is likely a common cold.
2) Pain in throat (R07.0) The patient has pain in his throat that causes difficulty swallowing.
3) Streptococcus unspecified (B95) Although the rapid antigen test was negative. It is not 100% conclusive. A throat culture was ordered to confirm if the rapid antigen test was a false negative. Strep throat cannot be ruled out here (Strep throat, 2018).
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:
I will not be prescribing any antibiotics or medications to this patient. Antibiotics are used for treating bacterial infections, and until the throat culture returns, there is no evidence for an infection. I recommend the patient to gargle a warm water, salt mixture whenever the pain intensifies. Throat candies may also help, they are sold at most convenience stores. The patient can also drink warm liquids such as tea, or even very cold liquids to soothe his throat (Pharyngitis, n.d.). If any other symptoms arise, bring the patient back to the clinic as soon as possible to re-evaluate. Follow up in 5 days to review results of the throat culture.
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
Pharyngitis – sore throat: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved May 11, 2020, from https://medlineplus.gov/ency/article/000655.htm
Strep throat. (2018, September 28). Retrieved from https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338
*ALL references must be Evidence Based (EB)
1 | P E D I A T R I C S O A P N O T E
1 | P E D I A T R I C S O A P N O T E
1 | P E D I A T R I C S O A P N O T E
2 to 20 years: Boys Stature Weight-for-age percentiles-for-age and
NAME
RECORD #
W E I G H T
W E I G H T
S T A T U R E
S T A T U R E
lb
30
40
50
60
70
80
lb
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
kg 10
15
20
25
30
35
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
cm
cm
150
155
160
165
170
175
180
185
190
kg 10
15
20
25
30
35
105
45
50
55
60
65
70
75
80
85
90
95
100
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
12 13 14 15 16 17 18 19 20
AGE (YEARS)
AGE (YEARS)
40
90
75
50
10
90
75
50
25
10
113 4 5 6 7 8 9 10
97
3
97
3
62
42
44
46
48
60
58
52
54
56
in
30
32
34
36
38
40
50
74
76
72
70
68
66
64
62
60
in Date
Mothers Stature Fathers Stature
Age Weight Stature BMI*
SOURCE: Developed b (2000).
y the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/growthcharts
Published May 30, 2000 (modified 11/21/00).
25
2 to 20 years: Boys Body mass index-for-age percentiles
NAME
RECORD #
2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
26
24
22
20
18
16
14
12
kg/m 2
28
26
24
22
20
18
16
14
12
kg/m 2
30
32
34
BMI
BMI
AGE (YEARS)
13
15
17
19
21
23
25
27
13
15
17
19
21
23
25
27
29
31
33
35
90
75
50
25
10
85
Date Age Weight Stature BMI* Comments
97
3
95
SOURCE: Developed b (2000).
y the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/growthcharts
Published May 30, 2000 (modified 10/16/00).
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triplets2004
Week2SOAP.docx
Home>Nursing homework help>week 3
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME:
DATE OF ASSIGNMENT: 05/11/2020
Patient Initials: J.T.
Date of Encounter: 05/06/2020
Sex: Male
Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL
SUBJECTIVE
Historian: Patient J.T.
Present Concerns/CC: My throat has been hurting recently
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, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes.
HPI: (must include all components – OLD CARTS)
Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while.
Medications: (List with reason for meds)
Patient not currently taking any medication
PMH:
Allergies: Dog hair, cat hair
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: 32 years old, no current health problems
Father: 34 years old, no current health problems
Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status)
Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family.
Review of Systems (ROS)
General
Denies fevers, chills, nausea, and vomiting
Cardiovascular
Denies chest pain, pressure, palpitations
Skin
Denies lesions, itching, or redness.
Respiratory
Denies shortness of breath, denies cough, denies difficulty breathing
Eyes
Denies blurred vision, denies visual loss, denies double vision
Gastrointestinal
Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools.
Ears
Denies hearing loss, pain, or drainage
Genitourinary/Gynecological
Denies painful urination, denies increased frequency
Nose/Mouth/Throat
Positive for throat pain 3/10. Positive for some 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 98 lbs.
Around 73rd percentile
Temp 98.1 F
BP 113/78 bp
Height 61 inches, 51
Around 92nd percentile
BMI: 18.5
Growth chart at bottom of SOAP Note
Pulse 89 bpm
Resp 17 rr
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
Skin around the nose, eyes, and mouth is normal for age. No presence of comedones, or papulopustules. No cyanosis, clubbing or bruises.
HEENT
Head is normocephalic, atraumatic. Eyes: PERRLA, no conjunctival or scleral infection. Ears: bilateral TMs pearly grey with positive light reflex. Neck: supple, full ROM. Mouth/Throat: Throat is visibly red, and inflammatory. No presence of blood detected. oral mucosa pink and moist, dental caries, gag reflex present.
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, tender to palpation. No masses. Bowel sounds present in all four quadrants. No ascites, no splenomegaly, no hepatomegaly. No rebound, no guarding
Breast
N/A
Genitourinary
No CVA tenderness. 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)
Rapid strep antigen test- Negative for strep throat
Throat culture pending results
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
Tanner Stage 2. When asked, the patient states that he has begun to grow some pubic hair, and his voice has been cracking lately. This is characteristic of the early stages of puberty at Tanner stage 2. (Emmanuel & Bokor, 2019).
HEADSS Assessment (Katzenllenbogen, n.d.)
H- Lives with his parents in Miami, FL. Has lived at their 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- Goes to school at a local middle school. Taking online classes due to COVID-19 pandemic. The patient has good grades and feels safe at school. He is unsure of what life he wants to lead.
A- Plays videogames with his friends mostly. He goes out with his parents and brothers sometimes before the pandemic.
D- He states that he has never been in contact with or ever experienced being around anyone with drugs of any kind.
S- The patient states that he has never thought about or ever tried to commit suicide. He has never felt depressed.
S- The patient states that he has never had sex. He has never been sexually abused by anyone in his family or any strangers.
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) Acute pharyngitis, unspecified (J02.9) The most likely diagnosis is a sore throat. It can be caused by many things including colds, the flu, or bacterial streptococcus (Pharyngitis, n.d.). In this patients case, it is likely a common cold.
2) Pain in throat (R07.0) The patient has pain in his throat that causes difficulty swallowing.
3) Streptococcus unspecified (B95) Although the rapid antigen test was negative. It is not 100% conclusive. A throat culture was ordered to confirm if the rapid antigen test was a false negative. Strep throat cannot be ruled out here (Strep throat, 2018).
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:
I will not be prescribing any antibiotics or medications to this patient. Antibiotics are used for treating bacterial infections, and until the throat culture returns, there is no evidence for an infection. I recommend the patient to gargle a warm water, salt mixture whenever the pain intensifies. Throat candies may also help, they are sold at most convenience stores. The patient can also drink warm liquids such as tea, or even very cold liquids to soothe his throat (Pharyngitis, n.d.). If any other symptoms arise, bring the patient back to the clinic as soon as possible to re-evaluate. Follow up in 5 days to review results of the throat culture.
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
Pharyngitis – sore throat: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved May 11, 2020, from https://medlineplus.gov/ency/article/000655.htm
Strep throat. (2018, September 28). Retrieved from https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338
*ALL references must be Evidence Based (EB)
1 | P E D I A T R I C S O A P N O T E
1 | P E D I A T R I C S O A P N O T E
1 | P E D I A T R I C S O A P N O T E
2 to 20 years: Boys Stature Weight-for-age percentiles-for-age and
NAME
RECORD #
W E I G H T
W E I G H T
S T A T U R E
S T A T U R E
lb
30
40
50
60
70
80
lb
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
kg 10
15
20
25
30
35
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
cm
cm
150
155
160
165
170
175
180
185
190
kg 10
15
20
25
30
35
105
45
50
55
60
65
70
75
80
85
90
95
100
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
12 13 14 15 16 17 18 19 20
AGE (YEARS)
AGE (YEARS)
40
90
75
50
10
90
75
50
25
10
113 4 5 6 7 8 9 10
97
3
97
3
62
42
44
46
48
60
58
52
54
56
in
30
32
34
36
38
40
50
74
76
72
70
68
66
64
62
60
in Date
Mothers Stature Fathers Stature
Age Weight Stature BMI*
SOURCE: Developed b (2000).
y the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/growthcharts
Published May 30, 2000 (modified 11/21/00).
25
2 to 20 years: Boys Body mass index-for-age percentiles
NAME
RECORD #
2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
26
24
22
20
18
16
14
12
kg/m 2
28
26
24
22
20
18
16
14
12
kg/m 2
30
32
34
BMI
BMI
AGE (YEARS)
13
15
17
19
21
23
25
27
13
15
17
19
21
23
25
27
29
31
33
35
90
75
50
25
10
85
Date Age Weight Stature BMI* Comments
97
3
95
SOURCE: Developed b (2000).
y the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/growthcharts
Published May 30, 2000 (modified 10/16/00).
Applied Sciences
Architecture and Design
Biology
Business & Finance
Chemistry
Computer Science
Geography
Geology
Education
Engineering
English
Environmental science
Spanish
Government
History
Human Resource Management
Information Systems
Law
Literature
Mathematics
Nursing
Physics
Political Science
Psychology
Reading
Science
Social Science
Home
Blog
Archive
Essay
Reviews
Contact
google+twitterfacebook
Copyright © 2019 HomeworkMarket.com
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