Soap Note for a Pediatric Patient

Daily Routine:

The patient is taken care of at the nearby daycare during the day and is picked up by the mother in the evening.

Safety:

The mother is always alert for any emergencies that arise from the daycare. She thoroughly checks on the child in the evening when picking him up.

Developmental:

The patient pulls himself to stand and move. He can sit without being held up or leaning on anything. The toddler creeps, scoots, and belly crawl on his knees and hands. S.B. holds onto the furniture while standing.

Nutrition:

The child feeds on bottled milk; the mother rarely breastfeeds him.

Allergies: Seasonal mild allergies that come and go.

Medication Intolerances:

No known intolerances to medication.

Chronic Illnesses/Major traumas:

No childhood diseases or chronic health conditions.

Hospitalizations/Surgeries:

No overnight surgeries or hospitalization.

Immunizations:

The patient is the only child in his family living with both the father and the mother. The boy loves to interact with anyone who gives him attention. He loves to play with objects and always shows a smiling face. The mother always ensures that the son is safe from injuries and potential diseases. Both the father and the mother are non-smokers or do not use other illegal drugs.

Constitutional symptoms: The mother admits that the child has very high fevers of about 103F which is associated with seizures. However, she denies vomiting, appetite loss, diarrhea or even headache.

The patient is unhappy and has very high fevers. He seems like someone who wants to sleep and is not interested in interacting or playing.

The mother denies unusual hair growth, diaper rash, bleeding, pruritus, abnormal molds, ulcerations, cuts or burns.

The mother denies hemoptysis, coughing, respiratory infection, dyspnea or wheezing.

The boy looks sleepy; however, the mother denies teary eyes, pain, flashing lights or erythema.

The patient’s mother denies vomiting, loss of appetite; the child looks as if he has abdominal pain, abdominal bleeding or nausea.

The mother denies seeing discharges from the ears or infection.

The mother highlights that she did not see her child having urination frequency, hesitancy in urination, dysuria, urgency, nocturia, or odorous urine.

The mother denies a sore throat, sinusitis or dental pain.

The mother denies broken bones, muscular pain or torn muscles.

The mother denies her son showing signs of pain or breast growths.

The mother admits her son having febrile seizures that last for about 2 minutes. The seizure experienced happens once in 24 hours.

The mother denies bruises, anemia, night sweats, blood clots, and swollen glands.

The mother denies insomnia or anxiety.

The patient has high fevers of above 103F and is unhappy. The boy is WDWN with NAD. He looks well dehydrated and is breathing normally.

The skin has no discoloration, ulceration, burns or bruising. There is no noticeable skin infection or scars.

Head- Normocephalic with the circumference of 48cm. No evidence of trauma.

Nose- There are no polyps, edema, tenderness, or discharge

Ear- There is no edema, discharge, or inflammation. Ears are small.

Eyes- Slanting eyes upwardly, PERRLA, normal pupils and cornea

Throat- visible dental carries, midline trachea, normal gag reflex, no JVD, non-exudate tonsils, non-enlarged tonsils.

No cyanosis, clubbing, murmuring, gallops or clicks. RRR, S1, and S2 are present.

No wheezing, rales, or rhonchi. Clear to auscultation in both lungs. No adventitious sounds bilaterally. Symmetric chest expansion.

No hepatosplenomegaly, bowel sounds present in all of the four quadrants, non-distended, soft, and non-tender.

Outline of the breasts is symmetrical and normal.

Descended testes, normal circumcised penis, non-tender, and no other noticeable abnormalities.

Full ROM in all extremities. The muscle tone is normal. 5/5 strength.

Presence of febrile seizures that lasts less than two minutes. Seizures occur within a 24-hour period. However, there is intact two-point discrimination sense, intact sharp and dull sensation, intact graphesthesia and stereognosis, intact CN II-XII, and intact positioning sense.

No withdrawn characteristics, good eye contact, and look unhappy.

· Blood test-Virus/bacteria test (Roseola)- Pending.

· Head CT scan-normal

1. Early Childhood Developmental Screening to check whether neurologic ailment (febrile seizures) has adversely affected the boy and what interventions are needed to resolve the situation (Moodie, Daneri, Goldhagen, Halle, Green, & LaMonte, 2014).

2. Stages and Ages Questionnaire to check whether neurologic ailment has negatively affected the child’s fine motor movement, communication, social development, and his capability to solve problems (Singh, Yeh, & Blanchard, 2017).

· Simple febrile seizures (ICD-10-CM, R56.00)

SFS is the main diagnosis and not the complex febrile seizure (CFS) based on the fact that the later lasts longer compared to the former. The patient experienced seizures that lasted for about 2 minutes which confirms SFS. CFS takes longer over 5 minutes and longer and occurs repeatedly within the day (Seinfeld & Pellock, 2013). Seizures are febrile because they are associated with high temperatures as manifested on the boy.

Differential Diagnoses

· Brain tumor (ICD-10-CM, D33.2)

The brain tumor is included in the diagnosis due to the fact that the child was experiencing seizures without a clearly identified cause. Brain tumors are sometimes associated with seizures which happen to the patients (Vecht, Kerkhof & Duran-Pena, 2014). In this case, the diagnosis was ruled out based on the findings from the head CT scanning which revealed that there was no tumor in the brain.

Concussions with consciousness loss (ICD-10- CM, S06.0X1A)

This diagnosis is included in the differential diagnosis because in the developmental milestone, the boy pulls himself on the furniture while standing. This could cause unnoticed falls which could cause the injury of the brain. At times, brain injuries cause seizures, especially if the damage is sufficient; hence, the diagnosis should be checked (Bennett, DeWitt, Harlaar & Bennett, 2017). However, the head CT scan ruled out this diagnosis because there were no damages noticed.

Vaccine administered on this visit:

The boy was administered MMR which reacted adversely with the toddler causing fever of above 103F; hence, he is not supposed to be given another vaccine until his fever resolves (Oldfield & Stewart, 2016).

Vaccine forms issued:

It is recommended that the parents are issued with vaccination handout forms before any pending vaccination of their children (Ventola, 2016). Thus, the mother will be issued with Hep A, Varicella and Influenza handout forms today.

Medications:

The patient will be given fever control medications. He will take 10 to 15 mg/kg acetaminophen every four hours for fever (Temple, Zimmerman, Gelotte & Kuffner, 2017).

Laboratory tests:

Negative rapid alternating movement test, Pronator drift test, Tandem gait test, and Romberg test.

Diagnostic tests ordered:

Head CT scan test; MMR reaction test and Roseola detection test.

Parent’s education:

To educate the mother that vaccines are not harmful to toddlers and that they are important in keeping off other dangerous ailments. The parents should know that their child’s increased temperature was caused by mumps, measles and rubella immunization and not the virus or bacteria. This usually occurs about 7-14 days after vaccination but later resolves (Sawyer, Simon, & Byington, 2016). All they need to do is to follow the prescribed medication.

Non-medication treatments:

To give the patient enough brain rest which is to place him in a low stimulation environment.

Return the patient to the clinic in two days for the evaluation of the seizures and fever.