KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

PEDIATRICS

Student: Susan Kelly Course: 5023

SOAP Note: #4

Pt. Initials: A. A. Age: 13 DOB: 2/2/2005 LMP: 2/10/2018 Allergies: NKA

Immunization status: Up to date

Medications: Motrin 200mg PO Q 6hrs for elevated temperature per her father

Erickson’s Developmental Stage: 5-13 Industry vs. Inferiority

This is the fourth stage of development during this stage a balance between competence and

modesty. Children who are commended and commended by parents and teachers develop a

feeling of competence and belief in their ability.

It was very evident during my assessment the father spoke very highly of A. A. I am certain he

fosters this stage of development by commending her. A. A. is a modest teen which was also

very evident during my assessment.

(S)

Chief Complaint: A. A. complains of “not feeling well for three days.” A. A. States she “hurts all

over.”
HPI: Cough, fever, body aches, and red watery eyes

Onset: Three days ago

Location: Generalized

Duration: Constant

Character: “Achy allover.”

Aggravating/Associated: Temperature 101F last night resolved with Motrin. Temperature

101.1F this morning another dose of Motrin was administered.

Relieving: A. A. reports Motrin decreases the temperature and relieves the body aches.

Severity: Moderate on the Wong Baker scale

History: (Prenatal/birth history/medical history) Father reported mother had a vaginal delivery

he “thinks” she was forty weeks no reported complications. OB/GYN appointments followed as

physician requested prenatal vitamins taken throughout pregnancy and after birth. Mother

breastfed until a year old. Birth weight was seven pounds seven ounces. Father is unsure about

group B strep. No reports of gestational diabetes mellitus, hypertension, or pre-eclampsia.

Father reports mother did not use tobacco or alcohol use during pregnancy or after. Father

report the home is alcohol and tobacco free. APGAR score is unknown Father reports mother is

a G1 P1 A0. A. A. has no medical history to report. Father states all vaccines are up to date flu

vaccine was given in October 2017.

Surgical Hx: No surgical history reported

Social Hx: Attends public elementary school in the eighth grade, Father reports good social

interaction currently in Top Gun and attends Sunday School where she actively participates in

both.

Family Hx: Lives at home with birth parents (mother is 33 and father 36), no siblings and a pet

dog (poodle). The family is a single family living in a one level ranch style home built in 1990 a

remodel was just completed (energy efficient). Father reports the property being in a

subdivision and denies worrying about the neighborhood. Father feels the home and

neighborhood are a safe place to raise their child. Father reports both paternal and maternal

grandparents live close and are without medical disparities and have an active part in A. A.’s life

along with two aunt and uncles and four first cousins.

ROS:

General: Father reports temperature which Motrin relieved. A. A reports both chills and

sweating. A. A. reports eight to nine hours sleep at night without interruption. No reports of

nightmares or vivid dreams.

HEENT: See HPI

Skin: No reports of itching, rash, bruising, cuts or scratches.

Respiratory: No reports of shortness of breath at rest or with activity. No reports of cough,

sneezing, congestion, or wheezing.

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

GI: No reports of dysphagia, nausea, vomiting, diarrhea, cramping, daily BM without difficulty.

No reports of reflux, heartburn, loss or decrease of appetite. No reports of abdominal pain

GU: No reports of frequency, urgency, hesitancy, incontinence, dysuria, hematuria, or nocturia.

Diet: Regular, no recent changes. Reports eating three meals a day with a snack before bed.

Father reports minimal eating out they have family meals at home. A. A. eats a variety of food

without being selective. Breakfast varies from yogurt to cereal and milk. Lunch is typically a

sandwich with vegetables with ranch dressing, chips and fresh fruit. Dinner consist of a protein

and two sides one being a green and salad is offered daily. A. A. states she “likes” salad. A. A.

has milk at least two times a day one chocolate and one 2% with meals and juice or water with

snacks which is usually applesauce.

Endocrine: No reports of heat or cold intolerance, goiter, polyphagia, polydipsia, dry hair or

skin.

MS: Denies joint stiffness, muscle cramps, or swelling. No reports of difficulty with ROM or

ambulation.

Neuro: No reports of headache, seizures, loss of vision, hearing, speech, syncope or vertigo.

Psych: No report of anxiety, depressive behavior, agitation, hallucinations, or memory loss.

(O)

Vital signs: T 100.2 P 98 R 24 BP 110/68 HT 64 WT 130 pounds BMI 24.2 Pain

Moderate Wong Baker

Percentile on growth chart: WT 91 HT 77.6 HC N/A

Developmental status: Appropriate 83.6 percentile.

Constitutional: Very pleasant, well mannered, well groomed, well nourished, Caucasian female

sitting erect on the exam table. Dressed appropriate for age and weather. Very cooperative

made eye contact and interacted appropriately, actively participated in answering questions.

No guarding fidgeting or grimacing noted.

Head: Normocephalic, no infestations, flakes, abrasions, or raised areas on scalp, eyebrows,

crust noted on eyelashes.

Eyes: PERRLA 2 and brisk red reflex. Sclera white, pale yellow crust and periorbital erythema

noted.

Ears: Bilateral tympanic membranes visualized, pearly grey no redness or bulging noted.

Nose: Clear secretion bilateral nares.

Throat: Tonsils 2+ tonsils and pharynx no erythema or exudate, no lymphadenopathy noted.

Lymph: Not pertinent

Skin: Warm, dry intact cheeks erythematous.

Chest/Lungs: Resonant throughout no wheezing, crackles, or rhonchi noted. Lung expansion is

symmetrical.
Heart/pulses: RRR, S1 S2 no murmur noted

Abdomen: Non-tender, non-distended, no reports of CVA tenderness

Genitalia: Not pertinent for this exam

Musculoskeletal: Full ROM to all joints no swelling or redness. No scoliosis noted

Neurological: Alert, oriented times four. Cranial nerves are intact.

Psych: Interacts appropriately no flat affect

(A)

Dx:

1- Influenza A J09.X2

2- Acute Sinusitis J01.9

Differentials:

1-Acute viral rhinitis J30.0

2-Bacterial conjunctivitis H10.021

3-Other Seasonal Allergic Rhinitis J30.02

(P)

Tests/Labs/Diagnostics:

Rapid Influenza test $25.00 (per clinic)

Treatment Plan: Motrin 200mg PO Q 4-6 hours PRN for temperature and body aches OTC

$12.16

Rest and increase fluids

Parent/Patient Education:

 Hand hygiene is very important as not to spread germs as well as not contracting illness.

If soap and water is unavailable hand sanitizer can be used.

 Keep something such as a small paper bag close to properly dispose of used tissues.
 Rest until flu is fully resolved

 Do not touch your eyes, nose, or mouth as the majority of germs are spread after
touching a contaminated object then touching eyes, nose or mouth.

 Drink enough fluids so that you do not become dehydrated.

o Look at your urine. Urine should be light yellow to nearly colorless.

o If you are drinking enough, you should urinate every three to five hours.

 Please notify the office is symptoms worsen

Immunizations given: Not pertinent

Preventive care:

 Well child visits yearly

 Always wear a safety helmet with elbow and knee pads when riding a bicycle, roller-

skating, or skateboarding.
 Always wear a seatbelt when ridding in a motor vehicle.

 Family fire escape plan was reviewed.

 Never talk to or take items from strangers; stranger danger discussed.

 Reviewed the need for daily exercise and limit time spend in front of the television and

playing video games to two hours a day. Suggested walking her dog daily.

 Daily bathing or showers with brushing teeth twice a day and flossing at least once a

day.

 Discussed firearm safety with father, instructed him to keep all firearms is a secured

locked area.

 Avoidance of soft drinks and increasing water intake. Eat 1200 kcal/day, at least two

cups of milk a day, three ounces of lean meat/day, one and a half cups of fruit/day, one

cup of vegetables/day, four ounces of grain/day.

 Reviewed next steps for vaccines sixteen to eighteen years: Meningococcal. Influenza

and pneumonia vaccines were also discussed.

 Discussed with A. A. the importance of keeping “private parts” private and to

immediately tell her parents if anyone attempts to touch her inappropriately. We

discussed the fact there was no secrets between her, her parents and her doctor. We

also talked about her home and the doctor office being “safe zones.”

 No school for seven days.

Noted in the EMR to reiterate preventative education during next visit when patient is more

focused and not acutely ill.

Follow-up instructions: Notify the office if symptoms worsen or no improvement in three days.

Follow-up as needed.

Discuss how you addressed at least 3 NONPF competencies during this visit:

1.Quality Competency

Uses best available evidence to improve quality of clinical practice continuously

Evaluates the relationships among access, cost, quality, and safety and their influence on health

care.

Evidence based practice was utilized in the treatment plan for this particular age group as well

as not utilizing unnecessary testing or treatment while avoiding unnecessary cost for the

patient.

2.Independent Practice Competency

Practices independently managing previously diagnosed and undiagnosed patients.

Provides the full spectrum of health care services to include health promotion, disease

prevention, health protection, anticipatory guidance, counseling, disease management,

palliative, and end of life care.

Uses advanced health assessment skills to differentiate between normal, variations of normal

and abnormal findings.

Advanced assessment skills were utilized to diagnosis, treat and educate both patient and the

patients father.
3. Scientific Foundation Competency

Critically analyzes data and evidence for improving advanced nursing practice.

Integrates knowledge from the humanities and sciences within the context of nursing services

Translates research and other forms of knowledge to improve practice processes and outcomes

This competency was met due the advanced knowledge learned through King University’s

Family Nurse Practitioner program signs and symptoms were taken into consideration along

with a detailed history and physical to reach a conclusive diagnosis.

References

Clinical Growth Charts. (2010) (p. 6). Retrieved from

https://www.cdc.gov/growthcharts/data/set2clinical/set2color.pdf

Dietary Recommendations for Healthy Children. (2014). Heart.org. Retrieved from

http://www.heart.org/HEARTORG/HealthyLiving/Dietary-Recommendations-for-

Healthy-Children_UCM_303886_Article.jsp#.WmJ-AzdG3IU

Epocrates Online. (2018) Online.epocrates.com. Retrieved from https://online.epocrates.com

Preventive Care Children. (2018). HealthCare.gov. Retrieved from

https://www.healthcare.gov/preventive-care-children/

GoodRx (2017). Motrin (Ibuprofen). Retrieved from https://www.goodrx.com/motrin?drug-

name=motrin