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PEDIATRIC EPISODIC SOAP NOTE

Student’s Name: Brianne Foster Date: 08/21/2019

Patient / Client initials: J.S. Age: 10

Gender: Male Ethnicity: Caucasian

SUBJECTIVE DATA

Chief
Complaint
(CC)
New patient presents to the office accompanied by his mother who is the
informant. Mother states that the patient complains of “sore throat and fever
for 3 days.”

History of
Present Illness Patient c/o sore throat and fever for 3 days. He states that his throat hurts
(HPI) really bad when he swallows and his throat feels raw. Mother states that his
temperature last night was 103 and he complained of a cough and ear pressure
as well as throat pain.

Location: throat

Quality: patient describes a feeling of rawness

Severity: 7 on FACES pain scale

Timing: symptoms started 3 days ago

Setting: Mother explains the patient came home from school 3 days ago
complaining of a sore throat.

Alleviating and aggravating factors: pain in throat is worse when the patient
tries to eat or swallow anything. It is also worse when he wakes up first thing
in the morning and at night before bedtime. Mother states she has been
giving him OTC Children’s Tylenol 12.5ml every 4 hours as needed for his
fever.

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Associated signs and symptoms: cough and ear pressure that started last night.
Mother states he has had a decreased appetite and has just not acted like
himself.

Past Medical
History (PMH)
No chronic health problems

Past Surgical
History (PSH)

None
OB/GYN
history
(if applicable)
n/a

Immunization
status Up to date on all vaccines; Mother states he
did receive a flu vaccine last year and will receive one this year.

Medications
No prescribed medications. Mother states she has been
giving him OTC Children’s Tylenol 12.5ml every 4 hours as needed for his
fever.

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Allergies

NKDA
Family History
(FH) Patient is an only child. Mother is 33 years old and father is 35 years old.
Mother reports no health problems for herself or the father. Maternal
grandmother is 54yo and has no known health problems. Maternal grandfather
is 55yo and has HTN. Paternal grandmother is 57yo and has a history of breast
cancer with a bilateral mastectomy but is now in remission. Paternal
grandfather is 60yo and has Type II diabetes.

Psychosocial or
Social History Patient will be in the 5th grade this school year. He is very active and plays
(SH) football for his school. He was also on a summer league baseball team. Mother
states she and the father do not smoke. They do drink alcohol occasionally. He
is allowed to watch 1 hour of TV per day.

Nutritional
Screening if
applicable Mother states that patient eats cereal with 2% milk in the mornings, eats a snack
before lunch such as a granola bar, or nuts, and usually eats school food for
lunches or leftovers at home. Mother states she usually cooks grilled lean meats
with vegetables and a starch each night for dinner. She does admit that he
sneaks unhealthy snacks at times and will find packaging in his room.
Health
Maintenance Good compliance with annual check-ups with previous pediatrician; has an
appointment for Wellness exam October 2019.
Dental visit every 6 months; brushes teeth twice a day. No cavities at last
appointment that was 3 months ago.

Mother stresses importance of hand washing to child

Very active; physical activity for at least 1 hour per day. Allowed to watch 1
hour of TV per day.

Episodic visits
should include
ROS and
Physical Exam
only for body
systems

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relevant to the
complaint

Review of
Systems Mother reports fever, fatigue, and decreased appetite. Denies
(ROS) difficulty sleeping, chills, malaise, night sweats, unexplained
Constitutional weight loss or weight gain

Skin
Mother denies itching, urticaria, hives, nail deformities, hair loss, moles, open
areas, bruising, and skin changes. She states she applies
sunscreen while outside and inspects his skin regularly for any changes.

Eyes, Ears, Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma,
Nose peripheral visual changes, and dry eyes. No corrective lenses. Mother states
Throat/Mouth date of last eye exam was in 2018 and exam was reported normal (20/20
vision). Mother
reports sore throat and ear pressure. Patient states his throat hurts really bad
when he swallows and his throat feels raw. Denies headaches, hoarseness,
vertigo, sinus problems,
epistaxis, dental problems, oral lesions, hearing loss or changes, nasal
congestion.

Cardiovascula
r Mother states patient is very active and participates in sports. He participates in
physical activity for at least an hour per day. Denies any history of heart

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murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins,
edema.

Respiratory Mother reports cough that started last night. Denies history of
respiratory infections, SOB, wheezing, difficulty breathing, exposure to
secondary smoke, exposure to TB, hemoptysis.

Gastrointestin
al Mother reports patient has a decreased appetite. He complains of pain when he
swallows; dysphagia. Denies reflux, pyrosis, bloating, nausea, vomiting,
diarrhea, constipation, hematemesis, abdominal or epigastric pain,
hematochezia, change in bowel habits, food intolerance, flatulence,
hemorrhoids. Mother states she tries to prepare healthy, well-balanced meals.

Reproductive /
Genitalia / Mother denies urgency, frequency, dysuria, suprapubic pain, nocturia,
Genitourinary incontinence, hematuria, history of stones.

Musculoskelet Mother denies back pain, joint pain, swelling, muscle pain or
al cramps, neck pain or stiffness, changes in ROM. She states patient is active for
at least an hour per day. He does wear his seatbelt.

Neurological
Mother denies headache, weakness, numbness, tingling, memory difficulties,
involuntary movements or tremors, syncope, stroke, seizures, paresthesias.

Psychiatric
Mother denies nightmares, mood changes, anxiety, depression, nervousness,
insomnia, suicidal thoughts, exposure to violence, or excessive anger.

Endocrine
Mother denies cold or heat intolerance, polydipsia, polyphagia, polyuria,
changes in skin, hair or nail texture, unexplained change in weight, changes in
facial or body hair, changes in hat or glove size, use of hormonal therapy.

Hematologic Mother denies unusual bleeding or bruising, lymph node enlargement or


/Lymphatic tenderness, fatigue, history of anemia, blood transfusions.

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Immune
function / Mother denies seasonal allergies, allergy testing, exposure to blood or body
dysfunction fluids, use of steroids, or immunosuppression in self or family.

OBJECTIVE DATA
Physical Exam
General/
Consitutional Healthy appearing, well-nourished, and well-developed. Level of Distress:
NAD.

Vital Signs
Temp 98.6, BP 100/68, HR 74, RR 20, O2 sat 100%,
Height 4’ 11.5” (91st percentile), Weight 79lbs (59th percentile), BMI 15.7 (24th
percentile)

Skin
No scaling or breaks on skin, face, neck, or arms. No skin or subcutaneous
tissue masses present, no tenderness, skin turgor normal.

HEENT
Head: normocephalic, Eyes: sclerae white. Conjunctivae pink. Pupils are
PERRL, 3 mm bilaterally. Extraocular movements intact.
Ears: external appearance normal no lesions, redness, or swelling; on otoscopic
exam tympanic membranes clear, no redness, fluid, or bulging noted. Hearing is
intact.
Nose: appearance of nose normal with no mucous, inflammation, or lesions
present. Nares patent. Septum is midline. Mouth: pink, moist mucous
membranes. No missing or decayed teeth. Throat: Very erythematous (fire
engine red in appearance). Inflamed uvula, pharynx, and tonsils. Tonsils 2+
bilateral, no exudate present. No lesions, ulcers, or masses present.

Neck

No evidence of nuchal rigidity, ROM intact. No lymphadenopathy

Respiratory
Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or
rhonchi

Cardiovascula
r S1, S2. Regular rate and rhythm, no murmurs, gallops,or rubs
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Carotid Arteries: normal pulses bilaterally, no bruits present. Pedal Pulses: 2+
bilaterally. Extremities: no cyanosis, clubbing, or edema, less than 2 second
refill noted.

Breast

n/a
Abdomen
abdomen soft and nontender to palpation, nondistended. No
rigidity or guarding, no masses present, BS present in all 4 quadrants.

Female
Genitourinary/
GYN n/a

Male
Genitourinary/ deferred
Prostate

Rectal
deferred

Musculoskelet
al joint stability normal in all extremities, no tenderness to
(including palpation.
frailty
evaluation if
applicable)

Neurological

Grossly oriented x3, communication ability within normal limits, attention and
concentration normal. Sensation intact to light touch, gait within normal limits.

Psychiatric
including Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm,
mental health/ and cooperative. Patient appears to be happy/content.
substance use
screening tools
and
interpretation
of results
Diagnostic
Information RAPID STREP GROUP A, THROAT
08/21/19
CPT code: 87880
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Results:
Strep: positive

ASSESSMENT: DIFFERENTIAL DIAGNOSES AND SUPPORTING DATA

3-5 differential Data in your Data in your findings Citation of evidence


diagnoses findings that that rule out this for accepting or
for each presenting support this diagnosis rejecting the
problem diagnosis diagnosis

Sore throat x3 days, Positive strep test Weber, R. (2014).


Viral pharyngitis fever, (Weber, 2014). Pharyngitis. Primary
fatigue, cough, Care, 41(1), 91-98.
pharynx is
erythematous
(Weber, 2014).

Patient c/o Positive strep test Weber, R. (2014).


Tonsillitis sore throat and (Weber, 2014). Pharyngitis. Primary
difficulty swallowing, Care, 41(1), 91-98.
fever. Tonsils are
edematous (Weber,
2014).

Patient c/o Positive strep test Weber, R. (2014).


Mononucleosis sore throat x3 days, (Weber, 2014). Pharyngitis. Primary
fatigue, fever (Weber, Care, 41(1), 91-98.
2014).

Sore throat x3 days, None. Ganti, L., & Ballinger,


Acute pharyngitis fever, describes pain B. (2018) How
as a feeling of accurate is rapid
rawness. Throat antigen testing for
very erythematous group A streptococcus
(fire engine red in in children with
appearance). pharyngitis? Annals of
Inflamed uvula, Emergency Medicine,
pharynx, and tonsils. 71(4), 523-524.
Positive rapid Strep
A test (Ganti &
Ballinger, 2018).

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Final ICD 10 diagnosis codes for the current visit

ICD 10 Code Corresponding Diagnosis


1. J02.9

Infectious pharyngitis
2. J02.0
Streptococcal sore throat

PLAN: TREATMENT PLAN

(For graded SOAP note submissions, include rationale for all components of treatment
plan and support with citations from peer-reviewed information)

Additional None at this time (Ganti & Ballinger, 2018).


diagnostic tests
needed

Treatments: Penicillin V potassium 250mg/5mL suspension


Pharmacological Sig: Give 5mL by mouth three times daily x 10 days.
Give one hour before or 2 hours after meals

(Weber, 2014)
Treatments:
Non- Salt water gargles, drink plenty of fluids, avoid contact with others, wash
Pharmacological hands frequently, get plenty of sleep (Ganti & Ballinger, 2018).

Patient
Education 1. Immediately call office if the pain becomes more severe or if dyspnea,
drooling, difficulty swallowing, and inability to fully open mouth develops
2. Increase fluid intake
3. Do not return to school for a full 24 hours
4. Replace toothbrush

(Weber, 2014)
Consultations
recommended
with n/a
rationale
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Disposition

Follow up: If no significant improvement in 3-4 days, patient should return for
re-evaluation or follow up with primary physician.

CPT Billing Codes Reflected in the Treatment Plan

CPT Code Corresponding Diagnosis


1. Office or other outpatient visit for the evaluation
and management of a new patient, which requires
99203 these three components: A detailed history; A
detailed examination; Medical decision making of
low complexity.
2. 87880 Infectious agent antigen detection by
immunoassay with direct optical observation

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Nova Southeastern University
Medical Clinic
Florida

Patient Name: John Smith 07/26/2009 Date: 08/21/2019

Rx

Penicillin V potassium 250mg

Dispense: #30 tablets

Sig: 1 tablet by mouth three times daily for 10 days.

Take 1 hour before or 2 hours after meals

Refill NR 1 2 3 4 5

Signature:

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