Soap Note for a an 8 year old boy

Soap Note for a an 8 year old boy

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Soap Note for a an 8 year old boy

CC “Sore throat”

The child’s mother discloses her 8-year-old boy has had a sore throat, headache, and fever for 3 days.

HPI

A.C. is 8-year-old who presented with a sore throat for the last 3 days. His mother mentioned that the child had difficulty swallowing (pain). A slight fever of 100.2°F. was noted. No signs of a runny nose or coughing. The patient describes his throat as being rough. He denies any earaches, abdominal pain, or nausea. The patient’s appetite is reduced probably due to pain during swallowing, although drinking fluids. He complained of severe pain when asked to swallow saliva. 

PMH

• No known allergy to medications, immunizations are up to date. 
• No history of any form of accident
• No history of chronic health problems.

Objective:

Vital signs: 

• Temperature: 100.2°F
• HR: 90 bpm
• RR: 18
• BP: 110/70.

The physical exam reveals swollen tonsils with a reddish shade and white discharge. Anterior cervical lymphadenopathy is present. No rash or oral lesions are noted. The lunges are clear to auscultation. The abdomen feels soft and shows no signs of tenderness.

Labs/Diagnostics

• Rapid Strep Test: Positive
• Throat culture: Pending
• CBC: WBC elevated at 12,000 cells/mcL
• 
   PEDIATRICS SOAP NOTE WRITING SAMPLE

Assessment:

1. Acute Streptococcal Pharyngitis (Strep Throat) (Miller et al., 2022).
2. Mild dehydration (probably due to reduced fluid intake)

Plan:

1. Medications:

• Amoxicillin 50 mg/kg/day for 10 days.
• Acetaminophen 10-15 mg/kg every 4-6 hours for fever and pain as needed (Miller et al., 2022).

2. Treatment:

• Encourage fluid increase to avoid dehydration.

• Allow resting at home; avoid school until 24 hours after starting antibiotics (DeWyer et al., 2020).

Follow-up:

• Schedule a reevaluation in 2-3 days if symptoms become more severe (DeWyer et al., 2020).
• Throat culture results pending, will adjust antibiotics if necessary.

Patient Education:
Proper hygiene to prevent spreading (handwashing, avoiding sharing utensils).

References

DeWyer, A., Scheel, A., Webel, A. R., Longenecker, C. T., Kamarembo, J., Aliku, T., ... & Beaton, A. (2020). Prevalence of group A β-hemolytic streptococcal throat carriage and prospective pilot surveillance of streptococcal sore throat in Ugandan school children. International Journal of Infectious Diseases, 93, 245-251.

Miller, K. M., Carapetis, J. R., Van Beneden, C. A., Cadarette, D., Daw, J. N., Moore, H. C., ... & Cannon, J. W. (2022). The global burden of sore throat and group A Streptococcus pharyngitis: A systematic review and meta-analysis. EClinicalMedicine, 48.