PEDIATRIC CLIENT DATABASE
(Complete SOAP Note Format)
Clinical
Setting Pediatric Acute
Care
Primary
Care
S UBJECTIVE DATA
I. Identifying Data:
A. Initials: AGD Age: 3 DOB: 02/17/2011 Sex: Female Race/Ethnic
Origin: Latino
B. Informant Aunt and mother Reliability Mom speaks little English, Aunt is reliable and translating for mother.
C. Insurance: Alabama Medicaid
II. Chief Complaint: Reason or reasons for seeking medical attention. To be recorded in informant’s own words.
"Patient complaining that it hurts when she urinate, her abdomen hurts and she's running a fever aunt says"
III. History of Present Illness: Chronological narration of client’s present illness, including the seven variables.
Ms. AGD is a 3-year old Latina who presents to the clinic with mom and aunt for complains of dysuria that started about
5days ago. Aunty states patient has been toilet trained and has been using the bathroom herself and learning to wipe without help even when someone is there to assist. Mom makes it a point to assist patient wipe after urinating or having a BM, but since she works patient stays home with grandmother and they are not sure if that's exactly what’s happening because patient tries to be independent and imitates everything she sees. Associated symptoms includes increase urinary frequency which mom states within the past 3 days patient has had some unexpected secondary daytime enuresis because she can't make it to the bathroom on time and has complained of suprapubic pain. Mom denies patient complaining of any back pain. Mom states patient has been urinating very small amount about 2 -3 times an hour and denies patient increase has fluid intake or drinking of any caffeinated drinks. According to aunty, what she has noticed is urgency is making patient trying to hold her urine by squirming and she has noticed patient running back and forth to the bathroom. Mother and aunt deny seeing blood in patient’s urine and have not noticed any vaginal discharge on patient’s underwear and deny patient complaining of any perianal itching. Mom denies patient

having bubble baths, use spray in genital area or having any trauma to vaginal area.
Mom states patient ran a fever of about 101.7 for two days and was given Tylenol that helped for a few hours. Patient has had a decrease in appetite; patient has been able to drink some water and juice but will not eat like she normal dose. Denies patient having any nausea, or vomiting,constipation or encopresis. Patient has not has a recent throat infection or skin infection.
IV. Past Medical History
Prenatal History
No significant prenatal history
Perinatal
No significant perinatal history;
Neonatal
No Neonatal history
Communicable Diseases
No known communicable diseases
Developmental
Milestone Age 3: Child speech is clear; speaks Spanish uses sentences, understands and follows directions appropriately. She response to questions appropriately, parents understands speech, she interacts with peers, pretend play, rides a tricycle , stands on one foot; and copies circles.
Immunizations (type and date(s) administered)
Hep B- 02/19/2011- patient was 2 days old first of 3 doses of Hep B
2 Months immunization
Pentacel( DTAP,IPV, HIB)- 04/19/ 2011 - patient was 2 months of age
Hep B- 04/19/2011 - 2nd dose of Hep B
RotaTeq- 04/19/2011- 2 months of age
4 months immunization
Pantacel( DTAP, IPV, HIB) -06/21/2011- second dose
Prevnar ( PCV13)- 06/21/2011- second dose
Rotavirus( oral) - 06/21/2011-second dose
6 months Immunization
Pentacel (DTAP-IPV-HIP)- 08/30/2011 - Third dose
Prevnar ( PCV13) - 08/30/2011- Third dose
Rotavirus- 08/30/2011- Third dose
HEP B- 08/30/2011- Third dose
12 months immunization
Varicella- 04/17/2012
HEP A- 04/17/2012- first dose
Prevnar (PCV13) - fourth dose
15 month immunization
Pentacel ( DTAP, IPV, HIB)- 08/21/2012- fourth dose
MMR- 08/21/2012- first dose

HEP A- 08/21/2012- second dose
Influenza vaccine october 2013
Up to date on immunization until age 4-5 years
Operations & hospitalizations
Type Non to date
Age(s) N/A
Response to anesthesia N/A
Onset of Menses: N/A Dysmenorrhea? N/A
Pregnancies N/A Miscarriages N/A Abortions N/A
Social History
Personality: Patient is talkative with mom, aunty and grandmother but very shy among strangers
Habits: P atient loves to watch TV, play with dolls and dress up, likes hearing stories over and over
Mental Health : Shows affection to familiar family and friends, also shows wide range of emotion such as being sad, happy, or angry. Likes imagination and imitative play
School grade : N/A
Failed any grade? (if so explain) N/A
Peer relationships plays with other children and learning to share toys and take turns
Family History
Parents’ ages:
21 occupations: Waitress
Marital status: single
Step Parents
/guardian ages: N/A occupations N/A
Siblings’ ages:
N/A Family position: 1st
Sibling relationships: Patient is the only child but have cousins at home
Parents’ health (general plus any chronic illnesses/health conditions):
Mother No significant medical history
Father No significant medical history
Grandparents’ health
Maternal No significant medical history
Paternal Unknown
Review of Systems:
General: Appropriate weight and height for age, patient is positive for fever ,
Skin: Denies changes of color, texture, and no cyanosis, clubbing, edema, skin rashes, dryness, lumps, sores, cellulitis or bruising.
Head : Denies swelling/ redness,
Eyes : Denies swelling redness, itching drainage
ENMT: EARS: Denies change in hearing, ear pain or ringing in the ears. Nose: Denies nasal congestion or nose bleeds.
MOUTH: Denies no current problems with tooth pain, bleeding gums, or dry mouth.

THROAT: Denies Hoarseness
Neck: Denies neck pain
Respiration: Denies cough and SOB and chest tightness. Denies hemoptysis, or pain upon inspiration or expiration. No recent throat infection
Cardiac : Denies chest pain, no high blood pressure. Denies any extremity swelling or changes in temperature.
Gastrointestinal: Denies nausea, vomiting, hematemesis, complains of abdominal pain, no change in bowel habits, or heartburn.
Genitourinary: Patient complaining of burning sensation on urination, urinary frequency, Patient has previously been toilet trained but having unexpected daytime enuresis. No hematuria
Genital Female : Denies irritation or discharge
Peripheral Vascular : Denies any problem with
Musculoskeletal : Denies muscle pain or aches, arm or leg weakness, joint swelling.
Neurological : Denies headache, seizures, disorientation, anxiety, inability to concentrate, or difficulty with balance.
Hematology : complains of fatigue, denies any area of bleeding or bruising
Endocrine: Denies ay excess weight gain or weight loss patient is appropriate size and weight for his age
Psychosocial: Denies patient having frequent tantrums, patient is happy and answers questions appropriately when asked directly
Developmental: Denies noticing any developmental delays in patient.
Physical Examination:
Vital signs: Temp. 100.8 Respirations 22 (crying?) No Heart rate 88
Blood pressure 102/53 Head Circumference cms. %
Pulse oximeter % Length/height 40.5 cms % Weight 20.5 kg %
Skin: Skin pink, warm and dry without rash or lesion. Elastic with good skin turgor; capillary refill less than three seconds.
Head Normocephalic, atraumatic, symmetric, non-tender,
Eyes: Sclera white, conjunctiva pink, no icterus, excessive tearing, or exudate; lids nonremarkable and appropriate for race; no edema or lesions noted; PERRLA Visual acuity and extra ocular eye movements intact.
Ears Bilateral canals patent and non-tender, with no marked erythema. No edema, lesion, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light.
Nose: Bilateral nares non-congested without rhinorrhea; non-boggy, non-edematous turbinate, no drainage noted. Septum midline.
Mouth & Throat: Posterior oropharynx non erythematous, without tonsillar edema or exudate, uvula midline.
Mucous membranes pink, moist, without ulceration.
Neck: supple, non-tender. No cervical, submental, post auricular, or supraclavicular lymphadenopathy noted. No thyroid nodule or thyroidmegaly. Trachea midline.

Respiratory: Lungs clear to auscultation bilaterally, thorax symmetric, non-tender, with symmetric expansion, no use of accessory muscles or evidence of retractions.
Breath sounds vesicular bilateral with no wheezes upon auscultation; no crackles or rhonchi noted.
Breasts & Axillae: Deferred not related to HPI
Cardiovascular: RRR w/o murmur, rub or gallop. Crisp S1 and S2. Extremities warm, dry and well perfused with 2+ palpable bilateral radial and dorsalis pedis pulses.
Abdomen: Round, soft non-distended and suprapubic tenderness on palpation, with no rash, no palpable masses or hepatosplenomegaly. Bowel sounds active, no umbilical hernia. No CVA tenderness on palpation
Musculoskeletal: No deformities to joints noted. Normal gait, good range of motion.
Neurologic: Alert cranial nerve II-XII intact. Sensation intact to pin prick and touch throughout.
Lymph: No lymphadenopathy
Genitourinary: No anomalies, irritation, trauma, or erythematous labia, no foreign body in urethra or vagina
Rectal: no parasites noted.
Screening/Diagnostic Testing:
Date of last vision screening : 02/06//2014 Results: Able to read letters and shapes with no problem
Date of last hearing screening : 02/17/2011 Results: Passed bilateral
Date of last developmental screening 02/06/2014 Results: Within developmental milestone for age 3 years
Diagnostic Tests:
Urinalysis In-house CPT -81000
PH-7.0
Glucose-Neg
Bill_Neg
Ketone-potive specific gravity- 1.010
Blood- positive
Protein-positive
Urobilinogen-Neg
Nitrites-positive
Leukocytes-Positive
Lab pending:
Urine for Culture and sensitivity sent to EAMC Lanier lab
Assessment:
1). Urinary Tract Infection (UTI) ICD -9: 599.0 - symptomatology of dysuria that is worse at end of flow, urgency, frequency and suprapubic tenderness on palpation suggesting lower UTI. Patient’s urinalysis positive for leukocyte esterase, hematuria,

and nitrites, supporting the diagnosis of urinary tract infection.
2). Pyelonephritis: ICD-9: 590.80 :This is diagnosis is likely but not possible, patient is positive for, frequency, urgency,fever negative back pain, no CVA tenderness, urinalysis is positive for hematuria, and negative for Urobillinogen infection has not moved to the renal parenchyma still is in the lower urinary tract
3). Chemical Urethritis ICD -9: 597.80 this is less likely possibility, apart from dysuria, urgency, hematuria, Chemical urethritis is not accompanied by fever, mother and aunt denies patient ever having bubble baths, or spraying physical exam did not reveal any , irritation, erythematous labia or rash.
4). Mechanical Urethritis ICD -597.80 : Mom and aunty denies patient frequent horseback riding, negative physical exam, no foreign body in urethra or vagina.
5). Post-Streptococcal Glomerulonephritis ICD-9 : 580.0 ; This is not likely patient has not had any recent throat or skin infection in the last few weeks. This can be eliminated.
Plan:
1). Urinary Tract Infection ICD -9: 559.0: Based on subjective, objective and urinalysis the diagnosis is UTI
2). Start Sulfamethoxazole 200mg/trimethoprim (Sulfatrim) 40mg/5ml oral suspension dispense 200ml, no refills instruction; Take 2 teaspoon by mouth every 12 hours for 10 days
3). Increase fluid intake, make sure to keep patient hydrated
Sulfamethoxazole 200mg/trimethoprim (Sulfatrim) 40mg/5ml oral suspension
A) Indication for patient: Prescribed for treatment of bacteria urinary tract infection
B) MOA: Bactericidal; trimethoprim selectively inhibits dihydrofolate reeducates which is a folate antagonist and sulfamethoxazole competes with para-aminobenzoic acid, inhibiting folic acid synthesis.
C) Usual Peds Dose : 200mg/40mg/5ml
D Available as name brand generic or both: Available as both name brand Sulfatrim and generic as Sulfamethoxazole
/trimethoprim
E. Cost out the medication at 3 different pharmacies
Names of pharmacies
1) Publix Pharmacy 2900 E. university Dr. Auburn AL
2) Wal-Mart Pharmacy South college St, Auburn, AL
3) Sam’s Club Pharmacy 2335-Bent creek Rd, Auburn Al
F) Cost of Prescription at each Pharmacy
-Publix Pharmacy: Cash price 30 days supply for this particular medication is free, no coupon needed. There are some antibiotics that publix offer for free.
- Wal-Mart Pharmacy: Estimated cash price for a 30-day supply for generic is $69 and
$12.32 with a coupon.
And the price may be different and lower since patient is only given a 10-day supply
-Sam club Pharmacy: Estimated cash price for a 30-day supply of generic is $28 and
$12.32 with a coupon.

Education: Make sure patient complete all course of antibiotic. Increase fluid intake to prevent dehydration.
Adults should continue to monitor patient while she use the bathroom even though she is toilet trained to make sure she is wiping very well and learning to wipe from the right direction (front to back).
If patient continues to run high fever, nausea, vomiting or starts complaining of back pain or increase call the clinic and if the clinic is closed take patient to the ER.
Evaluation:
1). Follow up result of urine culture sensitivity and follow up with patient if needed
2). Follow up visit in two weeks for urinalysis recheck to make sure infection is cleared out completely or further workup is warranted.