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PEDIATRICS
SOAP Note: #4
Medications: Motrin 200mg PO Q 6hrs for elevated temperature per her father
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
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
(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
Location: Generalized
Duration: Constant
Relieving: A. A. reports Motrin decreases the temperature and relieves the body aches.
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
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
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
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
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.
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.
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.
symmetrical.
Heart/pulses: RRR, S1 S2 no murmur noted
(A)
Dx:
1- Influenza A J09.X2
Differentials:
Tests/Labs/Diagnostics:
Treatment Plan: Motrin 200mg PO Q 4-6 hours PRN for temperature and body aches OTC
$12.16
Parent/Patient Education:
Hand hygiene is very important as not to spread germs as well as not contracting illness.
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.
o If you are drinking enough, you should urinate every three to five hours.
Preventive care:
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.
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
Reviewed next steps for vaccines sixteen to eighteen years: Meningococcal. Influenza
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.”
Noted in the EMR to reiterate preventative education during next visit when patient is more
Follow-up as needed.
Discuss how you addressed at least 3 NONPF competencies during this visit:
1.Quality Competency
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.
Provides the full spectrum of health care services to include health promotion, disease
Uses advanced health assessment skills to differentiate between normal, variations of normal
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
References
https://www.cdc.gov/growthcharts/data/set2clinical/set2color.pdf
http://www.heart.org/HEARTORG/HealthyLiving/Dietary-Recommendations-for-
Healthy-Children_UCM_303886_Article.jsp#.WmJ-AzdG3IU
https://www.healthcare.gov/preventive-care-children/
name=motrin