Pediatric Soap Note 3

Chief Complaint: M.W.
is an 11-month-old AA infant accompanied by

her mother, S.W., who present to the clinic with the complaint of new
onset eye drainage and redness.
History of Present Illness: M.W.s mother S.W. noticed redness and
swelling of infants right eye this AM. Her eye was crusted shut.. M.W.
went to daycare but by afternoon infection had spread to the left eye
with yellow drainage from both eyes. Daycare called mom and patient
was sent home. Her eyes looked so much worse by this afternoon.
Mother also states that patients nose has been running constantly and
she has been fussy. No treatment attempts were made, S.W. brought
patient straight to clinic for evaluation.
Allergies: No Known Food or Drug Allergies
Current Medications: No Current Medications
Age/Health Status- 11-month-old healthy well developed infantBirthdate: 11/06/13
Immunization Status: Up-to-date on all immunizations.
Hepatitis B: at birth and 2 months of age
Rotavirus: 2 months and 4 months of age
DTAP: 2,4, and 6 months of age
HIB:2,4 months of age
Pneumococcal: 2,4,6, months of age
IPV: 2 months and 4 months
Plan to receive Flu-vaccination at next well visit
Prenatal: Unplanned pregnancy. Mother denies alcohol, drug, or
cigarette use during pregnancy. Father was present during pregnancy
and he was smoking.
Birth History: Full-Term vaginal delivery. Labor lasted 10 hours. Birth
weigh: 7lbs 6 oz. No infections at birth. Baby went home at 2 days old.
Family History:
Mother (28): Healthy and active
Father (30): Smokes Cigarettes, no other health conditions
Brother (2): Asthma.
Maternal Grandmother (55): Overweight with Hypertension,
Diabetes
Paternal Grandfather (deceased age 50): Died from Heart attack
Paternal Grandmother (58): No health problems.
Social History:
Mother is single.
M.W. lives in a home with mother, brother, and maternal
grandmother. No alcohol or smoking allowed in home.
Attends daycare 5 days a week while mother is at work. Mother
works in retail.
Review of Systems
Constitutional Symptoms: One ear infection and one URI since birth.
Otherwise healthy with appropriate weight gain and has reached
appropriate milestones for age.
Eyes: Yellow drainage, crust, and redness of both eyes. Mother states
M.W. has not been rubbing her eyes but I can look at her and tell she
does not feel well.
Ears, nose, mouth, and throat: Hearing acuity is intact. She has had
one ear infection since birth with no complications. Nose has clear, thin
continuous drainage that began 2 days ago. No trouble swallowing or
throat redness and pain.
Cardiovascular: No pertinent cardiac history
Respiratory: One URI since birth that was treated effectively with
antibiotics. Brother has asthma. No reports of grunting, wheezing, or
difficulty breathing.
Gastrointestinal: Child has no GI problems. Breast-fed for first 3
months and then formula. Has tolerated all foods that have been
slowly introduced into diet. No decreased appetite.
Genitourinary: No history of infections. Mother reports 7 to 8 wet
diapers per day.
Musculoskeletal: Baby is sitting up on own and taking steps. Move all
extremities equally.
Integumentary: No rash, lesions, or redness reported by mother. A
small amount of diaper rash as an infant, but no reports of severe
infections.
Neurologic: Normal neurologic development. Child is saying one to

two words. Waves bye-bye, smiles, and giggles appropriately.
Hematologic: No abnormal bleeding.
Allergic: No history of allergies, but mother reports a family history of
seasonal allergies.
Objective Data
Constitutional: Temp: 97.6, HR: 125, R: 25 BP:N/A. HT: 26 inches,
WT:20 LBS , 9.09 KG
Eyes: bilateral eyes appear inflamed, erythematous, with
mucopurelent 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. Turbinates pink and
healthy. No polyps or masses.
Throat: Tonsils normal size 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.
Genitourinary: Bladder not palpable. Diaper is dry.
Musculoskeletal: Moving arms and legs equally on both sides. Sitting
up on exam table with minimal assistance from mother.
Integumentary: No lesions, rashes, or skin abnormalities observed.
Neurologic: No neurological deficits noted.
Psychiatric: No psychiatric issues noted.
Hematologic: No bruising or abnormal bleeding noted.
Diagnostic Test:
Rapid-Strep Test- Negative
Flu-Swab- Negative
Assessment:
Level of Visit: 99201- outpatient visits of a new patient with self-limited
or minor problems.
Differential Diagnosis: Conjunctivitis
Episcleritis- unilateral more often than bilateral infection with no
discharge or eyelid matting. Unlikely diagnosis
Iritis- unilateral more often than bilateral. Unlikely diagnosis
Allergic Conjuctivitis- possible with the watery eyes, but not
usually associated with yellow discharge.
Lacrimal duct obstruction-possible because common in infants,
however not likely because this is generally in one eye not
bilateral.
Viral Conjunctivitis-possible diagnosis but not as likely to be
associated with yellow eye discharge.
Bacterial Conjunctivitis- caused by a bacterial infection, likely
bilateral with drainage, eyelid matting, red eyes, and yellow
discharge.
Problems:
Bacterial Conjunctivitis (372.30)
Plan
Medications
o Polymyxin B/Trimethoprim Opthalmic 10,000 units/1 mg/ml
sol
I drop in both eyes every three hours X 7 days.
MOA: Polymyxin B fights gram-negative bacteria;
Trimethoprim has a broad-spectrum effect and even
treats MRSA.
PolyTrim (brand name)
Pharmacy Comparison
Wal-Mart: $4.00
Target: $4.00
CVS Pharmacy: $12.07
Educated on how the infection is spread by contact with

infectious agent.
The importance of hand washing is stressed.
Orders to remain home from daycare until eye discharge has
resolved.
Return to clinic in 24 hours if condition worsens, if condition does
resolve no follow-up is needed for conjunctivitis.

Pediatric Soap Note 3

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What is the patient's chief complaint?

What is the suspected diagnosis?

Chief Complaint: M.W.

is an 11-month-old AA infant accompanied by

Paternal Grandmother (58): No health problems.

Neurologic: Normal neurologic development. Child is saying one to

Educated on how the infection is spread by contact with

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