Pediatric SOAP Note

Name: MM Date: 03/10/2018

Sex: Female Age/DOB/Place of Birth: 11 months old/April 28, 2017/ Miami, FL

SUBJECTIVE
Historian: Mother is beside with patient and appears reliable.
Present Concerns/CC: “My daughter has discharge and redness of her eyes.”

Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school
care; Sports/physical activity; Developmental Hx)

11-month-old African American female presented with drainage and redness in both eyes. Patient is in daycare x3 days a week with other
children around her age and has no developmental issues. Patient is always in her car seat or stroller when she is out with her mother and
family.

HPI: (must include all components)

11-mondth-old female presented with redness and swelling of infant’s right eye this AM. Mother reports patient’s eye was crusted shut. Mother verbalized
that she took patient to daycare but by afternoon infection had spread to the left eye with yellow drainage from both eyes. Daycare called Mother and patient
was sent home. Mother also states that patient’s nose has been running constantly and she has been fussy. No treatment attempts were made thus far.

Medications: (List with reason for med )

Disney Princess Multi-Vitamin Chewable, once daily

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PMH:

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major

traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up-to-date

Prenatal: Unplanned pregnancy.

Mother denies alcohol, drug, or

cigarette use during pregnancy.

Father was present during

pregnancy and he had been

smoking.

Birth History: Full term; vaginal

delivery. Labor lasted 10 hours

Birth weight: 7lbs 6 oz. No

infections at birth. Baby went

home at 2 days old.

Family History (Please identify all immediate family)

Mother: 29 years of age, healthy and active; no medical issues

Father: 29 years of age, smokes and drinks; no medical issues
Maternal Grandmother: 56 years of age, Alive, Diabetes and obesity (well controlled with diet and exercise)
Maternal Grandfather: Deceased at 52 due to heart attack
Brother: Age 2 with asthma

Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco,
and marijuana. Safety status

Mother is single. Patient lives in a home with mother, brother, and maternal grandmother. No alcohol or smoking allowed in home. Attends
daycare 3 days a week while mother is at work. Mother works in dental office as a receptionist. Patient’s father comes and goes but mother
reported that she is taking him to family court. Patient is always in her car seat when traveling or in her stroller when they go the park.
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ROS
General Cardiovascular

No pertinent cardiac history

Healthy with appropriate weight gain and has reached

appropriate milestones for age.

Skin Respiratory

Mother denies any skin changes, rash or bleeding. One URI since birth that was treated effectively with antibiotics.
Brother has asthma. Mother denies of grunting, wheezing, or
difficulty breathing.
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Eyes Gastrointestinal

Admits to yellow drainage, crust, and redness of both eyes. Child has no GI problems. Breast-fed for 3 months and then
formula. Has tolerated all foods that have been slowly
introduced into diet. No decreased appetite.

Ears Genitourinary/Gynecological
Mother admits to one ear infection since birth. With no No history of infections. Mother reports 7 to 8 wet diapers per
complications. Hearing acuity is intact. day.

Nose/Mouth/Throat Musculoskeletal
Nose has clear, thin continuous drainage that began 2 days Baby is sitting up on own and taking steps. Moves all
ago. No trouble swallowing or throat redness and pain. extremities equally.

Breast Neurological
Mother denies any changes, nipple discharge or pain Normal neurologic development. Child is saying one to two
words. Waves bye-bye, smiles, and giggles appropriately.

Heme/Lymph/Endo Psychiatric
No abnormal bleeding or heat or cold intolerance. Mother Mother admits to baby being fussier then normal but otherwise
admits to family history of seasonal allergies. were happy and playful.

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 20 lbs. BMI: 20.8 Temp F 97.6 BP N/A

Height 26 inches Pulse 125 Resp 25

General Appearance and parent‐child interaction:

Happy female 11 month old appears well developed and interacting with mother by smiling and giving “high fives”.

Skin

No lesions, rashes, or skin abnormalities observed.

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HEENT

Normocephalic, atraumatic with thick hair. Eyes: bilateral eyes appear inflamed, erythematous, with mucopurulent discharge
present in right eye. Eyelashes have a crust present. Eyelid edema present. Eyes appear watery. Ear: outer ear has no obvious
abnormalities. Otoscopic exam shows pearl gray tympanic membrane with no swelling or bulging with light reflex present.
Nose: thin clear mucous drainage from nose. Turbinate’s pink and healthy. No polyps or masses. Throat: Tonsils normal side
and uvula midline. No throat redness, swelling, or lesions present.

Cardiovascular

S1 and S2 auscultated with no murmurs or rubs.

Respiratory

Lung sounds clear in all lung fields. Respirations even and unlabored.

Gastrointestinal

Bowel sounds present in all four quadrants.

.
Breast

Symmetrical and normal size for age.

Genitourinary

Bladder not palpable. Diaper is dry.

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Musculoskeletal

Moving arms and legs equally on both sides. Sitting on exam table with minimal assistance from mother.

Neurological

No neurological deficits noted.

Psychiatric

No psychiatric issues noted.

In-house Lab Tests – document tests (results or pending)

Rapid-Strep: Negative
Flu swab: Negative

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)

PEDS assessment tool displayed that mother has no concerns or apprehensions of her daughter development and or behavior at this
time. Patient has and continues to meet all milestones appropriate for her age.

Diagnosis
 Pediatric SOAP Note
Differential diagnoses:
 Episcleritis (H15.109): Unilateral more often than bilateral infection with no discharge or eyelid matting. Unlikely diagnosis.
 Allergic Conjunctivitis (H10.45): Possible with the watery eyes, but not usually associated with yellow discharge.
 Lacrimal duct obstruction (H04.53): Possible because common in infants, however not likely because this is generally in one
eye not bilateral.

Primary diagnosis:
 Bacterial conjunctivitis (H10.021): Caused by a bacterial infection, likely bilateral with drainage, eyelid matting, red eyes, and
yellow discharge.

PLAN including education

Rx: Polymyxin B/ trimethoprim ophthalmic solution 10,000 units/ 1 mg/ml; every 3 hours for 7 days (maximum of 6 doses in 24 hours)
Instructions for using eye drops:
To instill the eye drops, follow these steps:
1. Wash your hands thoroughly with soap and water.
2. While tilting your head back, pull down the lower lid of your eye with your index finger to form a pocket.
3. Hold the dropper (tip down) with the other hand, as close to the eye as possible without touching it.
4. Brace the remaining fingers of that hand against your face.
5. While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid.
6. Remove your index finger from the lower eyelid.
7. Close your eye and tip your head down as though looking at the floor.
8. Place a finger on the tear duct and apply gentle pressure for 2-3 minutes.
9. Replace and tighten the cap on the dropper bottle. Do not wipe or rinse the dropper tip.
10. Wash your hands and if necessary your child's hands after instillation to remove any medication (U.S. National Library of Medicine,
2018)).
Patient Education: Avoid touching or rubbing eyes. This can worsen the condition or spread it to other eye. With clean hands, wash any
discharge from around the eye(s) several times a day using a clean, wet washcloth or fresh cotton ball. Throw away cotton balls after
use, and wash used washcloths with hot water and detergent, then wash your hands again with soap and warm water (Pflipsen,
Massaquoi, & Wolf, 2016). Wash pillowcases, sheets, washcloths, and towels often in hot water and detergent; wash your hands after
handling such items. Do not share personal items, such as pillows, washcloths, and towels. Disinfect all toys once she all her symptoms
have resolved. Do not use swimming pool until symptoms resolve as well.

Orders to remain home from daycare until eye discharge has resolved.

Follow-up: If symptoms get worse within the next 24 hours RTO.

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*ALL references must be Evidence Based (EB)

Self-Assessment of Patient Encounter:

Patient encounter went well. At first mother of patient was concerned that her daughter would have issues

with her vision due to how fast it spread while at daycare. However, during exam, mother began to

understand that this is common for children and was educated on how to prevent bacterial

conjunctivitis from here on out. She mentioned that she feels much more comfortable knowing that

she now has the tools to help her daughter get through this and gave me a hug verbalizing how

thankful she was for me taking the time out to fully explain how to treat and prevent conjunctivitis.

By the end of the encounter, patient has fallen asleep in her mother’s arms.

References

Pflipsen, M., Massaquoi, M. M., & Wolf, S. (2016). Evaluation of the Painful Eye. Am Fam

Physician, 93(12), 991-998. Retrieved from https://www.aafp.org/afp/2016/0615/p991.html

U.S. National Library of Medicine. (2018). Polymyxin B and Trimethoprim Ophthalmic:

MedlinePlus Drug Information. Retrieved from

https://medlineplus.gov/druginfo/meds/a616013.html