William Saliski
Pediatric SOAP Note
Subjective Data
ML - This is a 9yo Caucasian female. Most of the information was given by her but
she was accompanied by her father, Mr. L, also who gave more in-depth information
that was lacking from the patient.
CC - The patient presented today with a sore throat, nausea, and vomiting. She also
complained of a "headache and sore throat". She also stated that the "vomiting has
occurred 4-5 times since feeling like this and has had a temperature max of 102
deg".
HPI - Location - This complaint has started in the throat 2-3 days ago and led to a
feeling of nausea in the stomach accompanied with vomitting. Most of the pain now
is located in the back of the throat and it feels scratchy whenever she swallows. It
has been present for the past 2-3 days.
Quality - Patient complains of a sore throat that feels scratchy and swollen,
complained of fever and chills, poor appetite and intake, and vomiting 4-5 times non
bilious.
Severity - The impact of this illness has led to taking the child out of school and
unable to perform most ADLs. She feels weak and has felt like this for the past
couple of days. She is unable to eat at all with the present symptoms and had a temp
max of 102.
Timing - This has been occurring now for the past 2-3 days.
Setting - She has complained of theses symptoms at school and is what led to her
being taken out of school and brought home. Once home she still has felt the same
way and this is when the doctors office was called for an appt. She has been exposed
to strep in school.
Alleviating and Aggravating Factors - The only alleviating factor at this time is rest
and sleep. No medications have been tried at this time. Aggravating factors include
stimulation such as activity around the house and food or noxious smells.
Associated signs and symptoms - Nausea and vomiting 4-5 times non bilious, temp
of 102, fever and chills, headache, sore throat, and poor appetite.
PMH - This patient is not on any current medications nor has been on any.
Allergies - This patient has no known drug allergies at this time. She is also negative
for any environmental or latex allergies.
Prior Illnesses - No prior illnesses at this time.
Operations - No previous surgeries
Hospitalizations - No previous hospitalizations
Vaccines - She is currently up to date on her vaccines for a 9 y.o. and will not need
anymore shots until she is 11. She has been given information on the HPV and Hep A
vaccines as well since the family has not decided on whether or not she will be
getting them.
FH - This pt is an only child at the time of visit and she lives with her father since the
parents are divorced. She does still have living grandparents on her father and
mothers side with some family history. There are no real specific diseases that can
relate to the problems listed wrong with this patient.
Father - 32 y.o. with no significant history
Mother - 30 y.o. with no significant history
Grandfather - 63 y.o. with HTN, CABG, rheumatoid arthritis
Grandmother - 65 y.o. with gout, hyperlipidemia, and osteoarthritis
Grandfather - 67 y.o. with high cholesterol and HTN
Grandmother - 69 y.o. with no real significant history
SH - This little girl attends second grade at a local school and lives with her father as
mentioned earlier. Her parents have been divorced for almost 2 years and she visits
her mother on a routine basis.
ROS
Constitutional Symptoms - Patient is positive for fever/chills, poor appetite/intake,
fever 102 deg, and fatigue.
Eyes - No real issue with eye sight and no corrective lenses are needed at this point
in time. Normal vision
ENMT - No issue with ears, she has normal hearing without any devices, normal
nostrils and no problems with her mouth or teeth. She sees a dentist every 6
months. She does complain of a sore throat and a scratchy feeling when swallowing.
Cardiovascular - She has no cardiovascular issues at this time, does not complain of
nay activity intolerance outside of the recent issues nor ever complain of any chest
pain.
Respiratory - She is positive for a cough, is not around second hand smoke, and she
has never had a respiratory infection in her past. Does not have any underlying
respiratory issues.
Gastro - Patient is positive for abdominal pain, nausea and vomiting, and negative
for diarrhea. Does have normal bowel patterns, does not have any food intolerances,
and eats a regular diet with 2-3 cups of milk or dairy products a day.
Genitourinary - No complaints of any urinary problems at this time, does not have
incontinence, she is potty trained, and is not sexually active nor had her menstrual
period start yet (just in mentioning even though it is very early for this).
Musculoskeletal - Pt complaining of fatigue, does not normally have any fatigue
outside this illness, does use a safety belt and is able to sit in a normal seat in the
back of the car. She is involved in outdoor activities in her school.
Integ - She does not complain of any issues with her skin, she does use skin
protectant while outside in the sun, and she bathes usually once a day if not more
than that.
Neuro - No neurological disturbances at this time. Has never had a headache or
migraine.
Psych - No nightmares nor suicidal thoughts or tendencies. She is a happy child that
is always in a joyful mood.
Endo - No endocrine problems at this time to mention, she is at a healthy and stable
weight which does not fluctuate drastically.
Hemma/Lymph - Does not complain of any unusual bleeding or bruising. Does
complain of swollen cervical lymph nodes. Has never had a blood transfusion and
last H&H was when she was a baby.
Allergic/Immun - Does not have any seasonal allergies nor been tested for any other
allergies. Is up to date on Hep B titers and no current documentation of family
immunosuppression.
Objective Data
Constitutional - Temp 101.4, weight 83 lbs, height 54", awake alert and oriented x3,
comfortable in setting, well-developed, well nourished, no signs of acute distress but
looks fatigued and tired. (B/P and HR were not taken at this visit)
Eyes - Eyes were normal, eyelids normal, Conjunctiva normal, sclera normal.
ENT/Mouth - Normocephalic/atraumatic, no sinus tenderness, normal position of
ears, ear canal normal and no foreign body in ear, tympanic membranes normal,
nose clear, nose without deformity, nose with normal mucosa, mucous membranes
moist and pink, tongue normal, good dentition, Throat is red with palatal petechiae,
bilateral tonsillar hypertrophy but no tonsillar exudate.
Cardio - Regular rate and rhythm on auscultation, no murmur, capillary refill brisk.
Resp - Lungs clear to auscultation bilaterally, no increased work of breathing.
GI - Abdomen soft and non-distended, abdomen non-tender and no masses on
palpation. Bowel sounds are active
GU - This was not applicable for examination due to CC being upper resp/head and
has no connection to the urinary system.
Musculo - Strength is normal on standing, grips are equal, and no weakness was
visualized.
Skin - Warm and dry, no rash was seen. Hair is normal and evenly distributed.
Neuro - No involuntary movements noted, no weakness, or tremors seen. Pt is
oriented x3 and aware of the setting and situation she is in.
Psych - Pt seems to be in a calm mood and does not look depressed nor anxious
while she is being examined.
Hem/Lymph/Imm - Pt does not have any bruising or bleeding. The cervical lymph
nodes are swollen and tender on palpation.
Orders - Rapid Strep Screen: in-house lab
Results - Rapid Strep Screen: Positive
No other labs were sent out due to the in house lab being positive and the clinical
presentation of the patient.
Assessment
Diagnosis
1. Streptococcal Infection (primary) (034.0)
2. Pharyngitis (462)
There are no other labs that need to be ordered at this time due to the positive rapid
strep test and the clinical presentation of the patient. If the strep screen was
negative in house and she presented the way she did, then we can send out a strep
test for further evaluation and a second opinion. If we wanted to order other tests
that could be beneficial but more money spent, a CBC could be done to check WBC.
Like I said before though the rapid strep was positive so this is beneficial enough to
start the treatment plan mentioned next.
Acute Self-Limited Problems
The clinical presentation of nausea, vomiting, sore throat, headache, fever, chills,
poor appetite, cough, reddened throat, and swollen lymph nodes has led to the
diagnosis of strep throat and coding above.
Plan
Medications for treatment
Cefadroxil 250mg/5ml oral suspension
This is used to treat the streptococcal infection in her throat.
MOA - This is a cephalosproin which prevents cell wall synthesis by binding to
enzymes called penicillin binding proteins (PBPs). This disrupts the synthesis of the
peptidoglycan layer of bacterial cell walls. The antibiotic inhibits cell wall synthesis
by competitively inhibiting PBP cross-linking of peptidoglycan.
Dosage - 250mg/5ml which is given 1 1/2 tsp PO every day for 10 days.
Cefadroxil or Duricef (brand name)
Cost of medication
Walmart Chantilly Rd Mtg AL - $161 cash price, $20 generic with BCBS
Walgreens - Taylor Rd Mtg AL - 151.99 cash price, no information on how much
BCBS would be.
Adams Drugs - Taylor Rd Mtg AL - $90-$95 cash price. BCBS would be copay price.
Zofran for nausea
4mg disintegrating tablet 1 tab PO every 8 hours PRN nausea
Follow- Up - Pt should call if symptoms worsen in the next 3 days and do not start to
resolve with the initiation of antibiotics, but there will not be a follow up
appointment after this visit except for the next regular scheduled check up visit.
Pt Education - ML should not go to school for24 hours until after the start of
antibiotics and be on bedrest at this time.
Should drink plenty of fluids; as much as she will take to stay hydrated and then
push even more
Fever control - Alternate every 3 hours Motrin/Advil then Tylenol for the fever
Do not stop taking the antibiotics even if the symptoms start to resolve. Finish the
entire 10 days.
Take the Zofran according to the prescription for any nausea and vomiting she may
have
She can also do salt water gargles and use a humidifier
Call if symptoms worsen
Once symptoms resolve and antibiotics are done proper hand washing techniques
should be emphasized as to try and not catch another one of these infections since
they are contagious through contact.
Also be taught to avoid contact with people that have this in the future, do not share
food or utensils with these people, and know that it is going to take 5-7 days before
she feels back to normal but again finish the antibiotics.
She also needs to be taught that the antibiotics can upset her stomach and give her
diarrhea. She can eat a little yogurt with the medication to help soothe her stomach
and keep the diarrhea from starting.