SOAP Note on the Nick Roberts Pediatric Case (Case Study Sample)
Nick Roberts – Pediatrics
CC – Runny nose, cough and fever. 3asc/3pmh
Diagnosis – bilateral acute otitis media – URI, influenza, group A strep pharyngitis, pharyngitis, otitis media, laryngotraceobronchitis (croup), pertussis
Tests- rapid strep antigen detection test, rapid influenza diagnostic test, influenza PCR, Bordetella pertussis PCR
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Nick Roberts is a 2 year old boy brought in by his mother with a complaint of cough and coryza with 102F fever. His mother reports cough and runny nose started 2 days ago and fever began 24hours ago, Nick is not eating well and has less appetite – he currently goes to a daycare where several other children have gotten sick with similar symptoms. PE is positive for pharyngeal erythema and exudates. Nick has no history of medical conditions and has not had a flu shot this year.
CC: Nick Roberts is a 2 year old boy brought in by his mother with a complaint of cough and coryza with 102F fever.
HPI: His mother reports cough and runny nose started 2 days ago and fever began 24hours ago, Nick is not eating well and has less appetite – he currently goes to a daycare where several other children have gotten sick with similar symptoms
Meds: None
PMH: noncontributory
SH: Child lives with mother and father who are both smokers – they are looking for ways to quit.
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 85; BP – 95/60 RR – 20; T – 102.2F; SpO2 – 94%
Pharynx: Pharyngeal erythema and exudates.
Otoscopic exam: Bilateral tympanic membranes with erythema and severe bulging, immobility of membrane w/o discharge or purulence
ASSESSMENT/PLAN
Test Results:
Rapid Strep Test: Negative.
Rapid Influenza Diagnostic test: Negative
Influenza PCR nasal swab: Negative
Bordetella Pertussis PCR: Negative
Throat culture: Normal mixed flora. Negative for Group A Streptococcus.
Management Plan
Symptomatic pain management (acetaminophen, ibuprofen) – consult mother not to use aspirin.
Oral amoxicillin 10 days.
F/u call in 48 hours – if no improvement add clavulanic acid to regimen, or consider tympanocentrisis/myrigotomy if severe.
Nick Roberts Case Study-Soap Note
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Nick Roberts Pediatric Case Study-Soap Note
Subjective
Chief Complain
Runny nose, cough, and fever. "Well, two days ago, he started with a runny nose and a cough. Then yesterday, the daycare sent him home for a fever. He has also been fussy this morning and had a fever. So now we are on day 3 of him being unwell. I was hoping to get some medication for his cough today because I am not sure what is making him so fussy!" said the mother.
HPI
Nick Roberts is a two-year-old boy brought in by the mother with complaints of cough, coryza with a fever of 102F. The mother reports that the runny nose and the cough started about two days ago, and the fever began 24 hours ago. The runny nose is a symptom of URTI. The mother states that the most severe fever was 101F. However, the mother does not give any history of quality, timing, and modifying factors of the symptoms that Nick presented with.
Characteristically, the cough is not coming up with sputum. Additionally, the mother reports that Nick Roberts has reduced appetite and is not eating well. Nick currently goes to a specific daycare where many children have been sick with the same symptoms. Since the onset of the symptoms, no over-the-counter or herbal medication has been administered to the patient for cough. Still, Tylenol was administered every four hours whenever Nick had fevers. The fever always went away after the administration of Tylenol but always reoccurred after about four hours. The mother reports that the child has no rash, no episodes of nausea and vomiting, there is no discharge or bleeding from the ears, the mother has not noticed any pulling on his ears, and the mother thinks that the child has pain because he has been fussy.
Allergies
The mother reports that Nick has no allergy to medications, food, or other allergens.
PMH
There is no history of past medical illness. The baby has not yet received a flu shot because the mother claims it made him sick last year, so they decided not to give him this year. Plus, she cannot afford to lose more work days.
SH
The child lives with the father and mother, both smokers looking for ways to quit.
ROS
General; the p that the child has been since he is fussy. Skin; the mother does
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