SOAP Note One
Patient: TRJ Age:6yo Gender:Female Race: African American
CC: Per mom- "My child has been complaining of abdominal pain tonight and she vomited once."
HPI: Per mother, patient went to school today and came home and said her stomach hurt. She went to lay down and at dinner time stated she did not want to eat. Mother gave her a chewable pepto bismol and she vomited once after. Mother states she became tearful and pointed to her lower left side. Mother denies any known diarrhea. States up until dinner, child had been eating and drinking adequately throughout day. Mother reports no known fever.
PMH:
Allergies: Penicillin (rash)
Medical History: Pneumonia (2011)
Surgeries:None
Vaccinations: Specific dates of vaccines unknown to mother but states all school immunizations UTD
Medication List:
None
FH: Asthma (younger sister), Diabetes (maternal grandmother), HTN (maternal grandmother)
SH: Full time student.
ROS: (most information per mother- patient sleeping for beginning of exam)
Constitutional- Mother denies known fever, chills, weight loss
Head/Eyes- Mother denies any noted drainage from eyes. Patient denies any pain or itching to bilateral eyes. Negative for eye glasses use.
ENMT- Mother denies any recent nose bleeds, sinus congestion, post nasal drainage or reports of sore throat.
Cardiovascular- Mother denies any unusual SOB with age appropriate activities. No recent complaints of chest pain.
Respiratory- Mother denies any known cough, congestion, or hemoptysis.
Gastrointestinal- Positive tonight for abdominal pain and nausea/vomiting. Mother denies any appetite loss prior to this evening's set of events, denies any known constipation, diarrhea, flatulence, heartburn. Last stated BM today.
Genitourinary- Mother denies any known discharge or complaints of vaginal pain. States she has been urinating frequently the past two days.
Musculoskeletal- Denies any recent injury or fall. Denies any known deficits in age appropriate activities.
Integumentary- Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or irritation.
Neurological-Mother denies any complaints of headache. Has noted no gait abnormalities or recent falls.
Psychiatric- Mother states no known history of depression and participates appropriately for age in all activities and conversations.
Endocrine- Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time appropriate for midnight.
Hemtologic/Lymphatic- Mother denies any increase bruising or history of anemia.
Allergic/Immunologic- Mother denies any known exposure to bodily fluids or seasonal allergies.
Objective Data:
Physical Exam:
Constitutional- Well nourished, well developed for age. Temp: 97.7, HR 84, RR 24, O2 sat 100% on RA. (No BP measured per protocol only required on patients 7yrs and older unless warranted) Weight: 20.3kg
Head/Eyes- Normocephalic, PERL, Conjunctiva clear with no drainage noted.
ENMT- TM normal, no exudate noted in bilateral ear canals, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted.
Cardiovascular- regular rate, capillary refill < 3sec. No gallop or murmur noted.
Respiratory- Breath sounds clear and equal bilaterally. Equal chest rise and fall.
Gastrointestinal- Bowel sounds heard in all four quadrants. Soft, No tenderness or distention noted upon palpation. Patient negative for rebound tenderness. Negative for murphy's sign, rovsing's sign or tenderness at McBurney's point. No palpable mass or hernia. Abdominal series completed and showed normal bowel gas pattern and no acute disease in chest or abdomen.
Genitourinary- U/A showed cloudy urine with 1+ bacteria, 1+ Leukocyte esterase, Specific gravity 1.024, pH 5.5, Bili- negative, ketones-negative. No outward vaginal exam done at this time due to patient's age and acute care visit setting- exam not warranted.
Musculoskeletal- Patient demonstrates full range of motion with no signs of pain.
Integumentary- General skin overview reveals no significant rash or other lesion
Neurological- Alert and appropriate for age. No signs of focal motor or sensory deficit.
Psychiatric- Patient's reactions are appropriate for age.
Hematologic/Lymphatic/Immunologic- No outward signs of bleeding, vital signs do not indicate severe anemia. Fatigue appropriate for midnight evaluation.
Assessment/Analysis:
CPT- 99203 (new patient-with detailed focused assessment)
Problem List:
UTI: (599.0)- Urinanalysis points to UTI. Mother admits to some urinary frequency and UTIs are common in girls of this age. Upon education mother admitted to frequent bubble baths.
Nausea: Nausea/Vomiting is sometimes associated with UTI. Ondansetron ODT given to help control as needed.
Plan:
Goals for primary diagnosis of UTI:
Short term goal: Complete course of ABX to resolve UTI.
Long term goal: Implementation of tips to avoid UTIs in place- patient also has a younger sister and implementation of this can also help with prevention of UTI for her.
Intervention:
1. Complete course of ABX. Prescription given for Sulfamethoxazole-trimethoprim 200-40mg/5ml oral suspension.
5ml PO twice daily for seven days. Dispense 70ml with no refills.
Medicine is available at target and walmart as a part of their $4 generic list program
If filled at publix, generic will be given free of charge (promoted to patient's mother)
2. Ondansetron ODT 4mg- Melt 1/2 tab in mouth every six hours as needed for episodes of nausea/vomiting. Dispense two tablets with no refills.
Education is key here. Mother educated on promoting good wiping technique and avoidance of bubble baths. Also told to avoid soaps with strong fragrances. Mother educated to encourage water and to promote frequent urination breaks in the future.
As far as diet- promoted bland diet for 24 hours and then advanced as tolerated. Told to avoid spicy foods as well as heavy foods with dairy products. Promoted use of Gatorade.
Evaluation:
Patient to follow-up with primary care provider in one week after finishing antibiotics. Told to return if patient begins to complain of back pain, increasing urinary symptoms, or fever.
CC: Per mom- "My child has been complaining of abdominal pain tonight and she vomited once."
HPI: Per mother, patient went to school today and came home and said her stomach hurt. She went to lay down and at dinner time stated she did not want to eat. Mother gave her a chewable pepto bismol and she vomited once after. Mother states she became tearful and pointed to her lower left side. Mother denies any known diarrhea. States up until dinner, child had been eating and drinking adequately throughout day. Mother reports no known fever.
PMH:
Allergies: Penicillin (rash)
Medical History: Pneumonia (2011)
Surgeries:None
Vaccinations: Specific dates of vaccines unknown to mother but states all school immunizations UTD
Medication List:
None
FH: Asthma (younger sister), Diabetes (maternal grandmother), HTN (maternal grandmother)
SH: Full time student.
ROS: (most information per mother- patient sleeping for beginning of exam)
Constitutional- Mother denies known fever, chills, weight loss
Head/Eyes- Mother denies any noted drainage from eyes. Patient denies any pain or itching to bilateral eyes. Negative for eye glasses use.
ENMT- Mother denies any recent nose bleeds, sinus congestion, post nasal drainage or reports of sore throat.
Cardiovascular- Mother denies any unusual SOB with age appropriate activities. No recent complaints of chest pain.
Respiratory- Mother denies any known cough, congestion, or hemoptysis.
Gastrointestinal- Positive tonight for abdominal pain and nausea/vomiting. Mother denies any appetite loss prior to this evening's set of events, denies any known constipation, diarrhea, flatulence, heartburn. Last stated BM today.
Genitourinary- Mother denies any known discharge or complaints of vaginal pain. States she has been urinating frequently the past two days.
Musculoskeletal- Denies any recent injury or fall. Denies any known deficits in age appropriate activities.
Integumentary- Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or irritation.
Neurological-Mother denies any complaints of headache. Has noted no gait abnormalities or recent falls.
Psychiatric- Mother states no known history of depression and participates appropriately for age in all activities and conversations.
Endocrine- Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time appropriate for midnight.
Hemtologic/Lymphatic- Mother denies any increase bruising or history of anemia.
Allergic/Immunologic- Mother denies any known exposure to bodily fluids or seasonal allergies.
Objective Data:
Physical Exam:
Constitutional- Well nourished, well developed for age. Temp: 97.7, HR 84, RR 24, O2 sat 100% on RA. (No BP measured per protocol only required on patients 7yrs and older unless warranted) Weight: 20.3kg
Head/Eyes- Normocephalic, PERL, Conjunctiva clear with no drainage noted.
ENMT- TM normal, no exudate noted in bilateral ear canals, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted.
Cardiovascular- regular rate, capillary refill < 3sec. No gallop or murmur noted.
Respiratory- Breath sounds clear and equal bilaterally. Equal chest rise and fall.
Gastrointestinal- Bowel sounds heard in all four quadrants. Soft, No tenderness or distention noted upon palpation. Patient negative for rebound tenderness. Negative for murphy's sign, rovsing's sign or tenderness at McBurney's point. No palpable mass or hernia. Abdominal series completed and showed normal bowel gas pattern and no acute disease in chest or abdomen.
Genitourinary- U/A showed cloudy urine with 1+ bacteria, 1+ Leukocyte esterase, Specific gravity 1.024, pH 5.5, Bili- negative, ketones-negative. No outward vaginal exam done at this time due to patient's age and acute care visit setting- exam not warranted.
Musculoskeletal- Patient demonstrates full range of motion with no signs of pain.
Integumentary- General skin overview reveals no significant rash or other lesion
Neurological- Alert and appropriate for age. No signs of focal motor or sensory deficit.
Psychiatric- Patient's reactions are appropriate for age.
Hematologic/Lymphatic/Immunologic- No outward signs of bleeding, vital signs do not indicate severe anemia. Fatigue appropriate for midnight evaluation.
Assessment/Analysis:
CPT- 99203 (new patient-with detailed focused assessment)
Problem List:
UTI: (599.0)- Urinanalysis points to UTI. Mother admits to some urinary frequency and UTIs are common in girls of this age. Upon education mother admitted to frequent bubble baths.
Nausea: Nausea/Vomiting is sometimes associated with UTI. Ondansetron ODT given to help control as needed.
Plan:
Goals for primary diagnosis of UTI:
Short term goal: Complete course of ABX to resolve UTI.
Long term goal: Implementation of tips to avoid UTIs in place- patient also has a younger sister and implementation of this can also help with prevention of UTI for her.
Intervention:
1. Complete course of ABX. Prescription given for Sulfamethoxazole-trimethoprim 200-40mg/5ml oral suspension.
5ml PO twice daily for seven days. Dispense 70ml with no refills.
Medicine is available at target and walmart as a part of their $4 generic list program
If filled at publix, generic will be given free of charge (promoted to patient's mother)
2. Ondansetron ODT 4mg- Melt 1/2 tab in mouth every six hours as needed for episodes of nausea/vomiting. Dispense two tablets with no refills.
Education is key here. Mother educated on promoting good wiping technique and avoidance of bubble baths. Also told to avoid soaps with strong fragrances. Mother educated to encourage water and to promote frequent urination breaks in the future.
As far as diet- promoted bland diet for 24 hours and then advanced as tolerated. Told to avoid spicy foods as well as heavy foods with dairy products. Promoted use of Gatorade.
Evaluation:
Patient to follow-up with primary care provider in one week after finishing antibiotics. Told to return if patient begins to complain of back pain, increasing urinary symptoms, or fever.