CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes

Student Name: 

Course:

Patient Name: (Initials ONLY): J. S

Date: April 30, 2024

Time:

Ethnicity: Hispanic

Age: 3

Sex: F

SUBJECTIVE (must complete this section)

CC: Parental concern about child's recurring fevers.

HPI: J.S, Patient presented with intermittent fevers over the past week, highest recorded temperature was 102°F. No other associated symptoms noted. Parents administered acetaminophen for fever control.

Medications: Acetaminophen for fever

Previous Medical History: None

Developmental History: Developmentally appropriate for age

Allergies: None

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Immunizations: Up to date

Hospitalizations/Surgeries: None

Health Promotion/Health Maintenance: Routine pediatrician visits maintained.

Nutrition/Diet: Balanced diet reported by parents.

Exercise/Regimen: None

Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None

Safety Measures: Appropriate car seat use reported.

Screening exams: Routine pediatric visits

FAMILY HISTORY (must complete this section)

M: Healthy

MGM: Hypertension

MGF: None

 F: Healthy

 PGM: Diabetes

PGF: None

Social History: Lives with parents in a smoke-free environment.

REVIEW OF SYSTEMS (must complete this section)

General: No weight loss or fever reported

Cardiovascular: No palpitations or cyanosis

Skin: No rashes or lesions

Respiratory: No cough or shortness of breath

Eyes: No redness, discharge, or visual disturbances

Gastrointestinal: No vomiting, diarrhea, or constipation

Ears: No ear pain or discharge

Genitourinary/Gynecological: No urinary frequency, urgency, or dysuria

Nose/Mouth/Throat: No congestion, runny nose, or sore throat

Musculoskeletal: No joint pain or swelling

Breast: N/A

Neurological: No seizures, tremors, or abnormal movements

Heme/Lymph/Endo: No bruising or swelling of lymph nodes

Psychiatric: No mood disturbances or behavioral changes

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight: 15kg

Height: 95cm

BMI: 16.6

BP: 120/80 mmHg

Temp: 37°C

Pulse: 100 bpm

Resp: 20 bpm

SPO2%:93%

General Appearance: Well-nourished, interactive child.

Skin: No rashes or lesions

HEENT: Head: Normocephalic, atraumatic; Eyes: Pupils equal, round, reactive to light; no discharge or redness; Ears: Tympanic membranes intact bilaterally; Nose: Nasal mucosa pink, no discharge

Throat: Oropharynx pink, moist

Cardiovascular: Heart sounds regular, no murmurs

Respiratory: Respiratory rate within normal limits, lungs clear to auscultation bilaterally

Gastrointestinal: Abdomen soft, non-tender, no masses or organomegaly

Breast: N/A

Genitourinary: Diaper dry, no signs of urinary tract abnormalities

Musculoskeletal: Extremities symmetric, full range of motion

Neurological: Alert and responsive, normal tone and reflexes

Psychiatric: Not applicable

Diagnostic Studies: None

Special Tests: None

DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)

Differential Diagnoses

1. Urinary tract infection (ICD 10 code: N39.0) 

Urinary tract infections (UTIs) in 3-year-olds can present with non-specific symptoms such as fever, irritability, and sometimes abdominal pain, necessitating prompt evaluation due to the risk of complications and potential long-term renal damage if left untreated (Autore et al., 2023). Diagnosis typically involves urine analysis and culture, with treatment consisting of appropriate antibiotics tailored to the identified pathogen.

2. Febrile seizure (ICD 10 code: R56.00)

Febrile seizures, commonly occurring in young children during episodes of fever, are typically brief, non-life-threatening convulsions, often benign but necessitating medical evaluation to rule out underlying causes and provide appropriate management strategies (Gould et al., 2023).

3. Gastroenteritis (ICD 10 code: A09)

Gastroenteritis, characterized by symptoms such as vomiting, diarrhea, and abdominal pain, is a common illness in children, often caused by viral or bacterial infections, requiring supportive care including hydration management and occasionally antiemetic or antidiarrheal medications (Jones et al., 2023).

Diagnosis

Viral illness (ICD 10 code: J12.89)

Viral illnesses in children can present with a wide range of symptoms, including fever, cough, runny nose, and sometimes rash, with management primarily focused on supportive care and symptomatic relief while monitoring for any complications (Kloepfer & Kennedy, 2023).

Plan/Therapeutics: 

Encourage adequate hydration and rest.

Diagnostics: None indicated at this time. Encourage supportive care, including hydration and fever management with acetaminophen.

Education Provided: Advised parents on fever management, encouraged follow-up if symptoms worsen or new symptoms develop.

Follow-up appointment scheduled in 24-48 hours if symptoms persist or worsen.

References

Autore, G., Bernardi, L., Ghidini, F., La Scola, C., Berardi, A., Biasucci, G., ... & UTI-Ped-ER Study Group. (2023). Antibiotic prophylaxis for the prevention of urinary tract infections in children: guideline and recommendations from the Emilia-Romagna Pediatric Urinary Tract Infections (UTI-Ped-ER) study group. Antibiotics, 12(6), 1040.

Gould, L., Delavale, V., Plovnick, C., Wisniewski, T., & Devinsky, O. (2023). Are brief febrile seizures benign? A systematic review and narrative synthesis. Epilepsia, 64(10), 2539-2549.

Jones, E. A., Mitra, A. K., Bisht, A., Edet, P. P., Iseguede, F., & Okoye, E. (2023). Probiotics in gastroenteritis in children: A systematic review. IMC J. Med. Sci, 17(010).

Kloepfer, K. M., & Kennedy, J. L. (2023). Childhood Respiratory Viral Infections and the Microbiome. Journal of Allergy and Clinical Immunology.