KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

PEDIATRICS

Student: Allison Rogers Course: NURS 5023 Care of Pediatric Populations

SOAP Note # 5

Initials: R.P.
Age: 5 years DOB: 07-28-2011 Ericksons Developmental Stage: initiative versus guilt

History provided by birth mother, B.P., which appears to be a reliable source.

(S) CC HPI: Sore throat and fine itchy rash all over for past two days
Character: Sore, achy throat; itching rash
Onset: Two days ago
Location: Throat; generalized skin
Duration: Continuous
Severity: Rates sore throat moderate on pain scale
Pattern: Continuous
Associated: Temperature 101F last night, resolved with ibuprofen. Denies additional
increases in temperature.

Medical/ surgical history (including birth history): Term cesarean birth due to failure to progress
with no complications, APGAR 8/9. Birth weight 6 pounds 5.5 ounces/ newborn discharge
weight 5 pounds 14 ounces; bottle feed without difficulty. No significant medical or surgical
history.

Family/Social: Lives at home with birth parents (mother age 36, dad age 33); no siblings. No
smokers living in home with the child, denies frequent exposure to cigarette smoke. No pets.
Attends Kindergarten in public school system.

Immunization status: Current and up-to-date

Allergies: Amoxil (rash)

Meds: Ibuprofen OTC PRN, denies additional prescription or over the counter medications.

ROS:
General: Reports temperature of 101F last night, denies additional fever, skin feeling hot to
touch, or complaints of chills. States just dont feel good.

HEENT: Reports sore throat x2 days, reports hurting when swallowing but denies difficulty
swallowing. Reports clear drainage from nose since yesterday. Denies itching, burning,
irritation, tenderness, or drainage of eyes, or ears.

Skin: Reports fine, itchy rash all over body x2 days. Denies new or different medications,
foods/drinks, insect/animal bites, detergents, or exposure to chemicals.
Respiratory: Denies cough, congestion, shortness of breath at rest or with activity.

Cardio: Denies chest pain, tightness, burning or funny feeling in chest.

GI: No change in appetite. Reports diarrhea x1 yesterday. Denies nausea or vomiting.

GU: (Not applicable to this focused exam)

Diet: Denies changes in diet (24 hour diet recall not applicable to this focused exam)

Endocrine: (Not applicable to this focused exam)

MS: Denies muscle aches, weakness, difficulty with movement or walking.

Neuro: (Not applicable to this focused exam)

Psych: (Not applicable to this focused exam)

(O) Vital signs T: 99.2F P: 120 R: 22 BP (not assessed) HT: 42 inches WT: 42 pounds
BMI: 16.7 Pain: Moderate (throat)
Constitutional: Caucasian female, dressed appropriate for age and weather. Cooperative, alert,
active at times, sitting on mothers lap.

HEENT: Normocephallic, no drainage noted from bilateral eyes or ears. Clear secretions noted
from bilateral nares; nares intact. Bilateral tympanic membranes visualized, pearly grey in color;
no redness or bulging noted. Tonsils 2+, tonsils and pharynx erythematous with white exudate
noted to bilateral peritonsillar area. No lymphadenopathy noted.

Skin: Warm, dry, and intact. Fine papular rash noted on anterior and posterior trunk, upper and
lower extremities. Scattered fine papular rash noted to cheeks, cheeks appear erythematous, not
hot to touch. Circumoral pallor noted.

Respiratory: Chest expansion symmetrical. Clear and equal bilaterally in all lobes.

Cardio: RRR, S1, S2 present. No murmur noted.

GI: Normoactive bowel sounds. Denies tenderness upon palpation, no organomegally noted.

GU: (Not applicable to this focused exam)

Endocrine: (Not applicable to this focused exam)

MS: (Not applicable to this focused exam)

Neuro: (Not applicable to this focused exam)

Psych: (Not applicable to this focused exam)

Other: Rapid strep test positive

(A)Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes ) (list as many

diagnoses as indicated)
J02.0 Streptococcal pharyngitis

Differentials:
1- J02.9 Acute pharyngitis, unspecified
2- J02.8 Acute pharyngitis due to other specified organisms
3- J36 Peritonsillar abcess
4- B37.9 Candidiasis, unspecified

(P) (Include costs of tests, medications, etc. can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html; www.epocrates.com,
http://www.goodrx.com)

Rapid strep test done in office.

According to Fair Health (2017), out of pocket cost for a person without insurance for detection
test for Strep (Streptococcus, group A) cost $30.

Prescription given for Azithromycin 200mg/5ml, take one teaspoon twice daily for ten days.
According to GoodRx (2017b), 60ml of azithromycin 200mg/5ml cost $35.40 with free coupon
from Rite-Aid, $43.23 at Wal-Mart with free discount, and $56.33 with free coupon from CVS.

Prescription given for Benadryl 12.5mg/5ml, take one teaspoon every six hours as needed for
itching.
According to GoodRx (2017a), childrens Equate allergy relief 18 count cost $8.30, childrens
allergy diphenhydramine (CVS brand) 36 count cost $23.99, and Benadryl childrens allergy 20
count costs $7.99.

Education: Scarlatina rash is common with group A beta-hemolytic streptococcus infection.

Finely papular (making the skin feel course, like sandpaper), blanches to pressure. Onset: 1-5
days following onset of symptoms or may be presenting symptom (Blosser, OKeefe, &
Sanderson, 2017)

Anticipatory Guidance: Always wear seat belt while in a vehicle, wear safety helmet while
riding bicycle, never talk to strangers, and need a plan for fire safety. Stressed importance of
participation in daily exercise; limit electronics to one- two hours per day. Eat a well-balanced
diet, limit soft drinks and sugary drinks, and drink plenty of water. Take a bath or shower daily,
brush teeth twice daily, floss at least once daily (Yousey, 2017, pp. 111-113).

Follow-up instructions: Notify MD if symptoms worsen or do not get better. Follow-up as

needed.
Other: May return to school on Wednesday (school excuse was given for today and tomorrow).
According to Blosser, OKeefe, and Sanderson (2017), children are generally considered non-
infectious 24 hours after the start of appropriate antibiotic therapy (p. 535).

Discuss how you addressed at least 3 NONPF competencies during this visit. (See NONPF
competency list)
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecom
petenciesfinal2012.pdf )

1. Health Delivery System Competencies

According to Thomas et al. (2014), health delivery system competencies can be met through
interprofessional collaborative partnerships. This competency was met through suggesting the
child not return to school until at least 24 hours of antibiotic had been taken, in hopes she is no
longer contagious and that the infection not be spread to others in the school system.

2. Ethics Competencies
Ethics competencies are met through integrating ethical principles in decision making and
evaluating the consequences of decisions (Thomas et al., 2014). This competency was also met
through suggesting the child not return to school until at least 24 hours of antibiotic had been
taken, in hopes she is no longer contagious and that the infection not be spread to others in the
school system.

3. Independent Practice Competencies

Thomas et al. (2014) states that independent practice competencies are met through the
implementation of screenings and diagnostic strategies in the development of diagnoses. This
competency was met through a thorough assessment, development of differential diagnoses, and
performing a rapid strep test to confirm suspicion of streptococcal pharyngitis.
 References

Blosser, C. G., OKeefe, C., & Sanderson, S. K. (2017). Infectious diseases and immunizations.

In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, C. G. Blosser, & D. L. Garzon

th
(Eds.), Pediatric Primary Care, 6 (ed.), (pp. 474-548). St.Louis, MO: Elsevier.

Fair Health (2017). Detection test for strep (streptococcus, group A). Retrieved from:

https://fairhealthconsumer.org/medical_cost.php

GoodRx (2017a). Childrens Benadryl, childrens diphenhist, childrens diphenhydramine.

Retrieved from: https://www.goodrx.com/children-s-benadryl?drug-name=children

%27s+benadryl

GoodRx (2017b). Zithromax (Azithromycin). Retrieved from:

https://www.goodrx.com/zithromax?drug-name=zithromax&form=bottle-of-oral-

suspension&dosage=30ml-of-200mg-

5ml&quantity=1&days_supply=&label_override=azithromycin

Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. Wolf,

A. (20142). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculites. Retrieved from:

http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor

ecompetenciesfinal2012.pdf

Yousey, Y. K. (2017). Developmental management of school-age children. In C. E. Burns, A. M.

Dunn, M. A. Brady, N. B. Starr, C. G. Blossser, & D. L. Garzon (Eds.) Pediatric Primary

Care, 6th (ed.), (pp. 101-120). St. Louis, MO: Elsevier.