Soap Note-Pediatric Impetigo Essay Paper
Soap Note-Pediatric Impetigo Essay Paper
Patient Particulars
| Patient initials: E.R
|
Age: 3years
|
| Gender: Male
|
Ethnicity/Race: White American Soap Note-Pediatric Impetigo Essay Paper |
| If pediatrics, child accompanied by:
Mother |
Yes |
SUBJECTIVE DATA
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| Chief Complaint (CC) | Reddish sores around the face for three days |
| History of Present Illness (HPI) | E.R is a three years old child accompanied to the hospital his mother due to reddish sore around the face that started three days ago. The sore started three days ago around the nose and spread to the mouth, trunk, and legs gradually. The sore has clear fluid in it. It is associated with fever, generalized body malaise, and diarrhea. However, the mother denies itchiness of the sores, erythema surrounding the sore, and pus.
|
| Past Medical History (PMH) | The child has had recurrent upper respiratory tract infection over six months. However, he has never been in hospital over a chronic illness. He is currently on cetirizine syrup and amoxicillin for upper respiratory tract infection. He has no known food and drug allergy. His immunization schedule is up to date. Soap Note-Pediatric Impetigo Essay Paper |
| Past Surgical History (PSH) | He has never undergone any minor or major surgical procedure. |
| OB/GYN history
(If applicable) |
The child was delivered via spontaneous vertex delivery at 40weeks. The mother attended four sessions of antennal visits. She has no pregnancy related complications. |
| Immunization Status | Age specific immunizations : up to date
Covid-19 vaccine status: not yet No history of immunization reactions |
| Medications | Current medications:
Amoxicillin 125mg PO three times daily for five days Tylenol 125mg PR three times daily for three days Cetirizine 5mg PO once daily for five days |
| Allergies | No known food or drug allergy
|
| Family History
(FH) |
He is the first born in his family. His mother denies history of family skin diseases and other chronic illnesses.
|
| Psychosocial or Social History (SH) | The child joined playgroup three weeks ago. He is active is playing activities. He interacts well with other children.
|
| Pediatrics:
Developmental Milestones 0-21 years of age |
The child is consistent in 2-3 word phrases. His speech is clear and can follow 2 unrelated steps. |
| Nutritional Screening if applicable | The child is healthy.
His height, weight, arm circumference, body mass index, head circumference, and skin fold thickness are normal for his age. |
| Living Will/Advance Directives/Advance Care Planning if applicable | Not applicable |
| Review of Systems
(ROS) |
|
| General
|
The child denies headache, night sweats, and weight loss |
| Skin
|
The child does not have skin itchiness, scaling, and hyperpigmentation |
| Head/Neck/Thyroid
|
The child denies neck pain, headache, dizziness, and difficult in swallowing. Soap Note-Pediatric Impetigo Essay Paper |
| EENT | The child denies eye and ear ache, running nose, congestion of the nose, throat pain, and eye discharge. |
| Cardiovascular
|
The mother denies fainting episodes, palpitation, orthopnea, bluish coloration of the mucus membrane |
| Peripheral Vascular | There is no bluish coloration of the extremities
|
| Respiratory
|
The patient denies coughing, running nose, chest pain, difficulties in breathing, and wheezing.
|
| Gastrointestinal
|
The patient denies abdominal pain, vomiting, nausea, constipation, and bloating.
|
| Reproductive/Genitalia/Genitourinary | The child denies dysuria, hematuria, polyuria, and swelling of the penis.
|
|
Musculoskeletal
|
The child denies joint pain, muscle pain, and numbness
|
| Neurological
|
The child has normal muscle tone. However, the mother denies of seizure, slow language and motor skills, and decrease in developmental milestones. |
| Psychiatric
|
The child denies insomnia, hallucinations, and nightmares
|
| Endocrine
|
The child does not have un-intended weight fluctuations, changes in blood glucose, and mood swings.
|
|
Hematologic/Lymphatic
|
The child does not have abdominal swelling and pain, night sweats, weight loss, and enlarged lymph nodes.
|
| Immune Function/Dysfunction | The child has a skin infection. However, the mother denies of eczema, failure to grow, weight gain, and enlarged lymph nodes.
|
OBJECTIVE DATA
| Physical Exam
General/ Constitutional |
The child is in a fair general condition. He appears healthy and well built. He is well kempt and calm. He is cooperative during the examination. He has no pallor, jaundice, cyanosis, dehydration, and edema. |
| Vital Signs
|
Temperature is 39.4, Pulses at 118 beats per minute Respirations, 30 breaths per minute, Height 40 inches, Weight 45 pounds, and BMI 19.77 kg/m2. |
| Pediatrics: Vital Signs | Head Circumference-48 cm
BP-98/66mmHg Growth Chart Percentages-appropriate weight and height for age |
| Skin
|
The skin has small superficial fragile bullae around the nose, mouth, neck, trunk buttocks, and the legs. The bullae spontaneously rapture and drain. |
| Head/Neck
|
The head is round and a-traumatic. There is no mass and swelling. The fontanels are closed. There is no peeling of the skull. The neck is soft with uniform color. There is no swelling and tenderness.
|
| EENT | The eyes have a normal shape and size. There is no redness and tearing. The ears have a normal size and shape. |
| Respiratory
|
The chest is symmetrical with no lower in-drawing. There is no flaring of nasal alae, and intercoastal resection. There is a resonant percussion note and clear lung fields on auscultation.
|
| Cardiovascular
|
The heart is at the 5th inter-coastal space MCL. The pulse rate is present at regular rhythm and rate. The heart sounds S1 and S2 are present. There are no murmurs.
|
| Peripheral Vascular | The peripheral pulses are present at a normal volume, regular rate and rhythm |
| Abdomen | The abdomen is round with a normal contour. It is soft with no organ enlargement. There is a tympanic sound on auscultation. There is no shifting dullness and fluid thrills. |
| Breast | The breasts are of normal size and shape. There is no oozing of the nipples. There is no palpable mass.
|
| Female Genitourinary/
GYN (If applicable) |
Deferred |
| Male Genitourinary/
Prostate (If applicable) |
Not applicable |
| Musculoskeletal
(Including frailty evaluation if applicable) |
The head and face is aligned verticle and mouth aligned horizontal. The child assumes an upright gait and posture. There is no obvious deformity.
|
| Neurological | The child is oriented to time, place, and person. The cranial nerves are intact. The motor, cerebellum, sensory, and reflex functions are intact. |
| Psychiatric Including Mental Health/
Substance Use Screening Tools and Interpretation of Results |
The child maintains eye contact. His speech is about sharing his interests and ideas. He uses non-verbal cues. His speech has a normal volume and tone. |
| Lymphatic
|
The child has no lymphadenopathy. He does not have lower limb swelling. |
| Diagnostic
Information |
Presence of an impetigo outbreak
Presence of post streptococcal glomerulonephritis |
PRIMARY DIAGNOSIS FOR THIS VISIT:
| ICD-10 Code | Primary Diagnosis(es) |
| 1.ICD-10 LO1.03
|
Impetigo
Impetigo is a highly contagious skin infection caused by staphylococcus aureus. It presents with coalescing lesions on the skin that begin as small vesicles. It is associated with pharyngitis, fever, malaise, and mild lymphadenopathy. Impetigo is common in school going children and often associated with post-streptococcal infection. Soap Note-Pediatric Impetigo Essay Paper |
DIFFERENTIAL DIAGNOSES/CHRONIC CONDITIONS AND SUPPORTING DATA:
| ICD-10 Code | |
| 1.ICD10- L20.9
|
Atopic dermatitis
Atopic dermatitis is an inflammatory disease of the skin often in childhood following a variable. Variables causing atopic dermatitis are environmental factors and immune cells. Clinical presentations are chronic eczematous skin lesions, epidermal thickening, and hypertrophy. Often, it is associated with family history of asthma, allergy, and atopic disease. |
| 2.ICD10- L25.9
|
Pediatric contact dermatitis
Contact dermatitis in children is the most common allergen among children. Common sources of allergen in children are jewelry, detergents, or toys. Common presenting symptoms are mild pruritus with burning sensations. |
TREATMENT PLAN
(For graded SOAP note submissions, include rationale for all components of treatment plan)
| Additional Diagnostic Tests Needed
|
Urine analysis to evaluate acute post streptococcal glomerulonephritis (Alhamoud, et al, 2021)
Potassium hydroxide wet mount for microscopy to detect bullous dermatophyte infection Bacterial culture and sensitivity to determine the cause of the skin infection
|
| Treatments: Pharmacological | Mupirocin cream apply OD Soap Note-Pediatric Impetigo Essay Paper
Amoxiclav 228.5mg P.O B.D for five days
|
| Treatments:
Non-Pharmacological |
Cleaning the infected skin with clean water and cloth
|
| Patient Education | Discourage touching of the lesions
Recommend proper cleansing of the skin traumas Avoid mixing with non-infected people to prevent transmission Ensure hygienic measure in overcrowded places
|
| Pediatrics: Anticipatory Guidance | The guidelines states that all children with impetigo should withdraw from school and daycare
Treatment of impetigo must include an oral antibiotic and topical antibiotic (Hall, et al, 2022). |
| Consultations/Referrals Recommended With
Rationale |
Refer the child to the dermatologist to rule out other skin diseases. Refer to a nephrologist to evaluate a post streptococcal glomerulonephritis.
|
| Disposition
|
Follow-up the patient after two weeks to ensure there is clearing of the lesion and check bacterial culture and sensitivity. |
CPT Billing Codes Reflected in the Treatment Plan
| CPT Code | Corresponding Diagnosis |
| 1. Office visit E/M code | |
| 2.culture and sensitivity | 87040 to 87158 |
| 3. mupirocin | 68462-180 |
| 4. Amoxiclav 228.5mg | G9313 |
| 5. Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office | 81000-81003 |
References
Alhamoud, M. A., Salloot, I. Z., Mohiuddin, S. S., AlHarbi, T. M., Batouq, F., Alfrayyan, N. Y., … & Alaskar, M. (2021). A Comprehensive Review Study on Glomerulonephritis Associated With Post-streptococcal Infection. Cureus, 13(12).
Hall, L. M., Gorges, H. J., Van Driel, M., Magin, P., Francis, N., & Heal, C. F. (2022). International comparison of guidelines for management of impetigo: A systematic review. Family practice, 39(1), 150-158.
ACON SOAP Note Template
Note: This template serves as a SOAP note guideline for the Adult and Pediatric patient population in the clinical setting. The SOAP note should be written in a S-O-A-P format.
Student’s Name: Date of Patient Encounter:
| Patient initials:
|
Age:
|
| Gender: Male Female Other
|
Ethnicity/Race: |
| If pediatrics, child accompanied by:
|
SUBJECTIVE DATA
| Chief Complaint (CC) | In patient’s own words. States the reason for the patient visit in patient’s own words. For a WELL visit, the chief complaint will be annual exam, check-up, etc. Soap Note-Pediatric Impetigo Essay Paper
Pediatrics: Child well visit, sick visit, etc. |
| History of Present Illness (HPI) | Must include onset, location, duration/radiation, characteristics, aggravating factors, relieving factors, timing, and severity (OLDCARTS). |
| Past Medical History (PMH) | Current/past medical problems with date of onset.
List all medical problems. |
| Past Surgical History (PSH) | Surgeries and procedures with date performed and outcome.
List all surgical procedures. |
| OB/GYN history
(If applicable) |
Gravida/Para. LMP. Last PAP/WWE with results. Last mammogram with results. History of STI. DEXA Scan.
Pediatrics: Pre-Natal History, Newborn Comprehensive History |
| Immunization Status | Age specific immunizations. Covid vaccine status.
List and describe any history of reactions. |
| Medications | Current medications: List medication name, dose, route, frequency, duration, and reason for taking |
| Allergies | List medications, foods, environmental, latex as well as how allergy manifested.
List Adverse Drug Reactions (ADRs). Distinguish Side Effect from ADRs. |
| Family History
(FH) |
2nd degree blood relatives (grandparents, parents, siblings, children):
Age, living/deceased, medical problem. |
| Psychosocial or Social History (SH) | Patient profile (sexual orientation, marital status, children), lifestyle risk factors (illicit drug use, alcohol use, smoking/pack year, exercise), employment history, education, religion, cultural history, support system, living arrangement, stressors, driving.
Military service/deployment. History firearm |
| Pediatrics:
Developmental Milestones 0-21 years of age |
|
| Nutritional Screening if applicable | Report findings from a nutritional screening tool used to interview patient Soap Note-Pediatric Impetigo Essay Paper |
| Living Will/Advance Directives/Advance Care Planning if applicable | Report patient wishes and name/relationship of DPOAHC (Health Care Proxy)
Advance Care Planning
Pediatrics: Special Needs |
| Review of Systems
(ROS) |
Subjective information only what the patient reports (example denies, or patient reports). Must document pertinent patient positive and negative findings. |
| General
|
|
| Skin
|
|
| Head/Neck/Thyroid
|
|
| EENT | |
| Cardiovascular
|
|
| Peripheral Vascular |
|
| Respiratory
|
|
| Gastrointestinal
|
|
| Reproductive/Genitalia/Genitourinary |
|
|
Musculoskeletal Soap Note-Pediatric Impetigo Essay Paper
|
|
| Neurological
|
|
| Psychiatric
|
|
| Endocrine
|
|
|
Hematologic/Lymphatic
|
|
| Immune Function/Dysfunction |
|
OBJECTIVE DATA
| Physical Exam
General/ Constitutional |
General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress |
| Vital Signs
|
Temperature, Pulses, Respirations, BP (Postural PRN), Height, Weight, BMI, O2 sat (if applicable) |
| Pediatrics: Vital Signs | Head Circumference
BP (start at 3 years of age) Growth Chart Percentages (until age 21) |
| Skin
|
|
| Head/Neck
|
|
| EENT | |
| Respiratory
|
|
| Cardiovascular
|
|
| Peripheral Vascular | |
| Abdomen | |
| Breast |
|
| Female Genitourinary/
GYN (If applicable) |
|
| Male Genitourinary/
Prostate (If applicable) |
|
| Musculoskeletal
(Including frailty evaluation if applicable) |
|
| Neurological | Mental status, cranial nerves, motor, cerebellum, motor, cerebellum, sensory, reflexes |
| Psychiatric Including Mental Health/
Substance Use Screening Tools and Interpretation of Results |
Document findings from depression screen, Mini-Mental Status Exam, CAGE, GAD, PHQ2/9 etc. Soap Note-Pediatric Impetigo Essay Paper
Pediatrics: Screen for Autism (MCHAT) |
| Lymphatic
|
|
| Diagnostic
Information |
Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit |
PRIMARY DIAGNOSIS FOR THIS VISIT:
| ICD-10 Code | Primary Diagnosis(es) |
| 1.
|
|
| 2. | |
| 3. |
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DIFFERENTIAL DIAGNOSES/CHRONIC CONDITIONS AND SUPPORTING DATA:
| ICD-10 Code | |
| 1.
|
|
| 2.
|
|
| 3.
|
|
| 4.
|
TREATMENT PLAN
(For graded SOAP note submissions, include rationale for all components of treatment plan)
| Additional Diagnostic Tests Needed
|
|
| Treatments: Pharmacological |
|
| Treatments:
Non-Pharmacological |
|
| Patient Education |
|
| Pediatrics: Anticipatory Guidance | |
| Consultations/Referrals Recommended With
Rationale |
|
| Disposition
|
Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment. |
Two Current Evidence-Based Guidelines and/or Peer-Reviewed Scholarly Journals to Support Patient Education and Treatment P
CPT Billing Codes Reflected in the Treatment Plan Soap Note-Pediatric Impetigo Essay Paper
| CPT Code | Corresponding Diagnosis |
| 1. Office visit E/M code | |
| 2. | |
| 3. | |
| 4. | |
| 5. Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office |
Soap Note-Pediatric Impetigo Essay Paper
