Pediatric Episodic SOAP paper

Subjective Data

Chief complaint: the child complaints of a headache and coughing for three days

History of presenting complaint: A.F is a 6years old female brought in by her mother complaining of a headache. The headache is of acute onset, throbbing, and intermittent at the bilateral temporal region and radiates to the occipital region.  Exertion and blowing the nose worsen the pain while resting and taking analgesics relives the pain. The timing of the headache is in the morning and evening during the cold weather, and it is so severe that it disrupts her morning and evening activities. The child has an acute onset cough that is productive with thick yellow mucus that is non-blood stain and not foul-smelling. The timing of the cough is in the morning and the evening,  associated with fever, fatigue, chills and rigors, running nose, vomiting, and throat pain. She denies ear pressure, tearing, anosmia, and eye swelling. Pediatric Episodic SOAP paper


Past medical history: the mother reports that the child suffered recurrent allergic rhinitis during the spring, upper respiratory tract infections, and diarrhea. She has a positive history of hospitalization at the age of one year due to severe allergic rhinitis and apnea. She denies chronic childhood diseases and blood transfusion.

Current medication:

  1. Tylenol 500mg PO three times daily for headache
  2. Cetirizine 5mg PO once daily or PRN for allergy

Allergies: she develops hives and rashes when she takes penicillin. She sneezes and itches when exposed to fur, pollen, dust, cold air, and smoke. She takes cetirizine to relieve the symptoms. She denies food allergies.

Immunization: the child’s immunization schedule is up to date. Her last influenza vaccine was three months ago. The mother denies a history of vaccine adverse effects.

Past surgical history: she denies minor and major surgical procedures.

Social history: the child is in grade one. She lives with her parents and siblings. Her parents are civil servants with fully paid health insurance cover. They live in a stone-built apartment on the outskirts of the city. They can afford three meals per day. Their house has a smoke detector and wears her seatbelt when riding in a car. She speaks fluently with correct grammar that is easily understood. She can follow more than three commands and concentrate for more than fifteen minutes. She has friends in her school and neighborhood. Her academic performance is above average. She interacts well with her classmates, teachers, and parents. She enjoys playing singing games and story-telling sessions. Pediatric Episodic SOAP paper

Family history: she is the third born in a family of three children. Her elder brother 15years old has asthma and her sister 10 years old has no record of chronic diseases. Her father is 38years old and has asthma and hypertension. Her mother is 35years old without a record of chronic diseases. Her paternal grandfather has COD due to smoking tobacco and her paternal grandmother has recurrent allergies. She denies a family history of cancer and mental health diseases.

Growth and development: the child was born 6 years ago at term through spontaneous vertex delivery, weighing 2800g, and has a good score. The mother denies a history of childhood diseases like pneumonia, meningitis, jaundice, and kernicterus. She has had normal developmental milestones like social smile at 4weeks, head support at two months, sitting with support at 6months walking without help at 18months, and clear speech by 5years. Her current weight is 36kgs, height of 1.28meters and a BMI of 21.9kg/m2.

Review of systems

General: the child denies night sweats, loss of appetite, and unexplained weight loss or weight gain.

HEENT: the child has a headache, running nose, nasal congestion, and throat pain. She denies visual loss, eye ache, ear pain, and loss of hearing.

Respiratory system: the child denies chest pain, wheezing, bloody sputum, and difficulties in breathing.

Cardiovascular system: the child denies syncope, dyspnea, dizziness, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and lower limb swelling.

Gastrointestinal system: she denies diarrhea, abdominal pain, constipation, reflux, bloating, nausea, and weight loss.

Genitourinary system: she denies increased urinary frequency, hematuria, nocturia, polyuria, oliguria, and dysuria.

Musculoskeletal system: she denies fractures, joint pain, and muscle spasms.

Neurological system: she denies facial droop, numbness of extremities, muscle weakness, and convulsions.

Endocrine system: she denies heat intolerance, weight gain, irritability, sweating, weight loss, odynophagia, and increased thirst.

Skin: the child complains of generalized itchiness when exposed to allergens. She denies stretch marks, yellowness, change in skin color, rash, and peeling of the skin.

Lymphatic: she denies blisters, frequent infections, lower limb edema, and skin hyperpigmentation.

Psychiatric: she denies anxiety, irritability, mood fluctuations, insomnia, loss of concentration, and loss of memory.

Objective Data

General: the child is calm and alert. She is frequently blowing her nose and coughing. She is dehydrated and has cervical lymphadenopathy. She has no pallor, jaundice, cyanosis, edema, and finger clubbing.

Vitals: her temperature is at 38.9 degrees celsius, her pulse rate at 96beats per minute, her respiratory rate at 24 breaths per minute, her oxygen circulation at 99% room air, weight is 36kgs, height of 1.28meters and a BMI of 21.9kg/m2.

HEENT: the eyes are pink and watery without peri-orbital edema, pallor, and jaundice. The mouth is pink and moist with a clean tongue. The tonsillar and pharyngeal region is swollen and erythematous.  The nose is erythematous with a sore at the septum. There is a post nasal drip with mucus accumulation. The nasal adenoids are red and swollen. There are no polyps and nasal tumors.

Respiratory system: the chest child has a fast breathing rate. She has no flaring of nasal alae, intercostal muscle resection, and lower chest wall in-drawing. There is a symmetrical chest expansion when breathing. There is a resonant percussion note and bronchial-vesicular breath sounds with transmitted sounds during exhalation, upon auscultation. There are no crackles, wheezing, rales, or stridor.

Cardiovascular system: the apex beat has normal cardiac activity. The heart sounds are present without murmurs. The P2 is not palpable and there are no parasternal heaves. The peripheral vessels are palpable with a normal volume, regular rate, and regular rhythm. There are no palpable bruits. There is no lower limb swelling and neck vein distension.

Abdominal examination: there are no abdominal scars, distension, caput medusae, hernia, and drains. The skin is warm and there is no guarding, tenderness, intussusceptions, and fecal impaction. There is no organ enlargement, fluid thrills, and shifting dullness. She has a normal external female genitalia with no discharge.

Psychiatric assessment: the child is calm and oriented to time, lace, and person. She maintains eye contact during the interview. She is expressive and her speech has a normal volume and tone. She is in a happy mood and has a congruent affect. Her judgment and insight are intact.

Musculoskeletal system: she assumes an upright posture. She has a good balance and coordination when walking. She has no flat foot or club foot.

Skin: her skin is pink, warm, and moist. She has no scaling and peeling.

Diagnostic Investigations

A throat swab for culture and sensitivity helps in the diagnosis of group A streptococcus infections. Group A beta-hemolytic streptococcal rapid antigen detection test is accurate in confirming GAS infections. Complete blood count with white blood cells different helps rule out the pathogens causing infections. Erythrocyte sedimentation rate and C-reactive protein are inflammatory markers that help determine the severity of the infection. Total serum IgE levels help to rule out allergic rhinitis. A chest radiograph helps to rule out bacterial pneumonia. A lateral neck radiograph helps rule out epiglottis. Blood gas analysis and chemistry panel help determine pneumonia infections.


The patient presents with a headache, cough, fever, fatigue, chills and rigors, running nose, vomiting, and throat pain. On examination, she has a fever, conjunctivitis, running nose, inflammation of the tonsil and pharynges, swelling of the nasal adenoids, anterior cervical lymphadenopathy, and transmitted sounds on chest auscultation. She has an illness of the upper respiratory tract.

Primary diagnosis

Pharyngitis J02.9

Pharyngitis is the inflammation of the pharynx or tonsil region, usually of viral or bacterial origin. Group A streptococcus is the common pathogen causing pharyngitis. It is common in school-going children 4 to 7 years old. The clinical presenting symptoms are throat pain, headache, fever, coughing, vomiting, joint pain, and myalgia. The patient may have a fever, tonsillar exudate, anterior cervical lymphadenopathy, dehydration, conjunctivitis, rhinorrhea, palatal petechiae, oropharyngeal vesicular lesions, and murmurs in acute episodes (Oliver, et al, 2018). Group A beta-hemolytic streptococcal rapid antigen detection test is accurate in confirming GAS infections in emergencies. Uncomplicated infectious pharyngitis is of acute onset, and is self-limiting for up to 7days. Viral pharyngitis presents with cough and rhinorrhea. This is the primary diagnosis because she presents with similar signs and symptoms. The indicated diagnostic investigations determine disease pathogenicity.

Differential Diagnoses

Allergic rhinitis J30.9

Allergic rhinitis is the inflammation of the mucus membranes of the nasal cavity. It affects the eyes, ears, nose, and throat. The inflammation is a result of excessive production of histamine, mast cells, prostaglandins, and leukotrienes due to exposure to extrinsic allergens. These cause the clinical symptoms, rhinorrhea, nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, post nasal drip, headache, fever, fatigue, drowsiness, and sleep apnea (Hoyte, F. C., & Nelson, H. S. 2018). Causes of allergic rhinitis are exposure to allergens like dust, fur, pollen, cold air, and dust. Risk factors are family history of asthma and allergic diseases, exposure to allergens, and recurrent allergic rhinitis. An allergy skin test is specific for allergic rhinitis and helps in making an accurate diagnosis. The patient presents with headache, fever, nasal congestion, rhinorrhea, and throat pain. Moreover, she has a family history of asthma and recurrent allergic rhinitis. However, this is not the actual diagnosis because the patient does not report exposure to an allergen.

Pneumonia J15.9

Pneumonia is a pathogenic infection of the lungs from exposure or manifestation of bacteria. Community-acquired pneumonia is the most common with a typical pathogen, streptococcus pneumonia. The presenting symptoms are productive cough, hyperthermia, tachypnea, use of accessory muscles for respiration, central cyanosis, altered mental status, and tachycardia (Hanada, et al, 2018). The patient has a deviated trachea, decreased intensity of breath sounds, crackles, rhonchi, dull percussion notes, and pleural friction rub. The diagnosis and severity assessment of pneumonia depends on the CURB-65 score whose parameters are age above 65years, confusion, respiratory rate, and urea. The patient presents with a productive cough, fever, and tachypnea. However, it is not the actual diagnosis because the patient has no central cyanosis, altered mental status, tachycardia, trachea deviation, decreased intensity of breath sounds, crackles, rhonchi, dull percussion note, and pleural friction rub.



Assess for air patency and initiate oxygen supplementation in cases of obstruction

Give saltwater gargles to relieve throat pain

Warm fluids help in loosening the mucus, flushing irritants, and reducing throat swelling. Pediatric Episodic SOAP paper


Before initiating antibiotic treatment, the patient should have a throat swab for culture and sensitivity to rule out GAS and viral infections (Dumkow, et al, 2018). In cases of a positive GAS throat swab, start the patient on cephalosporin like cephalexin 250mg PO twice daily for ten days to prevent the occurrence of glomerulonephritis. Penicillin is the first-line treatment method for pharyngitis but has been excluded due to penicillin allergy. Dexamethasone 0.5mg PO once daily for three days will relieve the coughing and running nose. Tylenol 500mg PO three times daily helps relieve headache and throat pain.


Pharyngitis is the irritation of the pharynx due to manifestation by a bacteria or a virus. It is often self-limiting depending on the severity of suppuration. It is common in children and elderly patients. The presenting symptoms depend on the pathogen causing the illness. Therefore, a throat swab for culture and sensitivity is important to help the nurse initiate the appropriate treatment. Viral infections are self-limiting and symptomatic relief methods are recommendable. However, in GAS, the patient takes antibiotics for 10 days to prevent the occurrence of rheumatic fever and post-streptococcal glomerulonephritis. Bacterial pharyngitis may complicate peri-tonsillar abscess, epiglottitis, herpes simplex virus, or suppurative cervical lymphadenitis. Complications arise from poor drug compliance, antibiotic resistance, and untreated close contact. However, the prognosis is good for bacterial, fungal, and viral infections.


The patient should present to the clinic five days after drug initiation to ensure the effectiveness of the drugs. A routine follow-up culture should be performed on patients with signs of rheumatic fever. In case of recurrent pharyngitis, it is important to screen and treat close contacts to avoid complications.

Patient Education

The patient should understand the course of ailment and treatment method. Advise the patient to complete the full course of antibiotic therapy despite the improvement of the symptoms. The patient should attend the follow-up clinic to evaluate the complications of the symptoms. Teach the patient about symptomatic relief methods like analgesics, taking warm liquids, and saltwater gurgles.

MSN Case Write Up Assignment

The purpose of the Case Write- Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.

Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.

Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.


If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write a note at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum or in parentheses in the plan.


You are learning to practice evidence-based practice. Support at least one item in the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your research is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

All case write ups are to be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will incur a penalty of 5 points per day including weekends (maximum deduction of 25 pt.). Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.

Episodic Write-up: Episodic visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally.  Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected.  Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.


This write-up should be 2-4 pages single spaced and concentrate on the most pertinent information. Not all the systems or sections from a comprehensive write up will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.

Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.  This write up should be 5-8 pages single spaced.

You must know how to delineate which visits are episodic versus comprehensive.  Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place!  Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!

Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.

Case Write-up Outline


Following the format of:



CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”

HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Surgical History: Past surgeries and rough dates when possible. Should also include traumas and hospitalizations

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit the indication (reason) for a specific drug being taken. Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history.  If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.


Allergies: Medications. Food allergies when applicable.

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For children, list dates for all immunizations.

Family History: It is generally appropriate to go back at least two generations.

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. In childbearing women, make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit).  For a young teen you can put “not sexually active” (but make sure you have asked).  This is sometimes tricky with teens being seen for general health problems but so very important.  If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.


Vital signs (BMI should be included on every visit)

Physical examination

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.


Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section.  Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.


List both your differential diagnoses and your presumptive diagnosis. Remember that these should be supported by findings in your history and physical exam. For a comprehensive exam, you should document at least three ICD code diagnoses.


Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed.

Coding Resource:

All write ups should include the billing codes.  We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up.  You should include both the E&M code (level of service) and the ICD-9 diagnosis codes. Your E&M code should be consistent with your patient visit. Pediatric Episodic SOAP paper


MSN Case Write-Up Rubric


Criteria Exceeds Expectations Meets Expectations Below Expectations No Effort
Chief Complaint


3 Points

Includes CC that includes the reason for visit, is appropriate for the type of write-up AND is in the patient/

family’s own words.

2 Points

Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words


1 Point

CC is not appropriate for the type of write-up AND is not in the patient/family’s own words


0 Points

 Not included

History of Present Illness


10 points

Provides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information.

HPI is focused and detailed.

Does not include any objective data

7 points

Provides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit. HPI is somewhat focused. Does not include objective data.

4 points

Provides a superficial HPI that misses 3 or more key components and/or does not include all pertinent information, includes irrelevant information OR includes objective data

0 Points

Not included

Medications 3 Points

Documents a comprehensive

Medication list that includes drug name (brand and generic), dosage, route, frequency and indication. Allergies are documented and includes reaction. Includes NDKA, if applicable.

2 Points

Documentation includes medication list but omits 1-2 details. Allergies are documented but does not include reaction.

1 Point

Documentation includes medications but omits 3 or more details. Allergies are not documented

0 Points

Not included

Pertinent History 10 Points

Provides comprehensive past medical history, surgical, family, social, and obstetrical history (when applicable). History is consistent with other documentation. Includes immunization information


7 Points

Provides a history but history is superficial AND/OR omits 1 -2 necessary details


4 Points

Provides a history but history of superficial and omits 3 or more details


0 Points

Not included

Review of Systems 10 Points

Complete ROS that addresses each physical system for a comprehensive visit and includes only necessary (but at least 4 systems) for an episodic visit.

ROS is completed with a clear narrative.

Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’

7 Points

Incomplete ROS that misses 3 or less components for a comprehensive visit OR includes inappropriate systems for an episodic visit


4 Points

Incomplete ROS that misses 4 or more components for a comprehensive visit AND/OR includes objective data


0 Points

 No ROS attempted

Objective Data 20 Points

Documents vital signs with documented BMI

Documents physical examination:

Each system addressed completely for comprehensive exam. Includes only necessary (but at least 4 systems) for an episodic visit. Include pertinent positive and pertinent negative findings.

Documents labs, diagnostic tests that are available for that visit.

14 Points

 Documents vital signs but is missing BMI

Documents an incomplete physical examination:

missing 3 or less components for a comprehensive visit and/or missing up to 3 pertinent positives/negatives OR

includes unnecessary systems for an episodic visit and/or assesses less than 3 systems

Documents labs, diagnostic tests that should be a part of the plan


8 Points

Does not document vital signs

Documents an incomplete physical examination:

missing 4 or more of the components for a comprehensive visit and/ or missing 4 or more pertinent positives/negatives


Includes unnecessary systems for an episodic visit and/or assesses less than 2 systems

Fails to document labs, diagnostic tests



0 Points

Not included

Assessment 14 Points

Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit.

Provides at least 3 diagnoses for a comprehensive visit

ICD-9 codes included with each diagnosis

9 Points

Provides a presumptive diagnosis but only includes 1-2 differential diagnoses


Does not include ICD-9 codes


4 Points

No differential diagnoses OR no presumptive diagnosis


0 Points

No differential diagnosis AND no presumptive diagnosis

Plan 20 Points

Provides a plan that includes appropriate labs/tests ordered that are pending

Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.

Plan includes both pharmacological and non-pharmacological interventions

Plan includes referrals and follow up details

Orders are appropriate for patient visit. Rationales and citations for sources of interventions

Coding and Billing included


14 Points

Missing 3 or more components and/or does not include dosing and instructions for medications and/or does not include Coding and Billing


8 Points

Missing 4 or more of the required components OR Plan is not supported by evidence and citations for sources of intervention are missing AND

Does not include Coding and Billing


0 Points

Not included or inappropriate to patient visit

Formatting/APA 10 Points

No errors in  grammar and spelling .

No errors in APA format

Write-up is in proper format and adheres to the appropriate page limits. Pediatric Episodic SOAP paper

7 Points

Up to 3 spelling or grammar errors OR 3 APA errors

Write-up is in proper format and adheres to the appropriate page limits


4 Points

Up to 3 errors in spelling and/ or grammar AND/OR APA errors AND

Write-up is not in proper format OR does not adhere to the appropriate page limits


0 Points

4 or more errors in spelling and/or grammar

AND/OR 4 or more APA errors


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