KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

PEDIATRICS

Student: Allison Rogers Course: NURS 5023 Care of Pediatric Populations

SOAP Note # 3

Initials: Z.B.
Age: 6 years DOB: 05-16-2010 Ericksons Developmental Stage: Initiative versus guilt

(S) CC HPI: Early Periodic Screening and Diagnostic Testing (EPSDT)

Character: Not applicable to this exam
Onset: Not applicable to this exam
Location: Not applicable to this exam
Duration: Not applicable to this exam
Severity: Not applicable to this exam
Pattern: Not applicable to this exam
Associated: Not applicable to this exam

Medical/ surgical history (including birth history): Mother denies any medical or surgical history
with the child (Did not provide birth history such as type of birth, complications, birth weight, or
birth length on standardized history form)

Family/Social: Lives with birth mother (did not provide age), birth father (did not provide age),
and older sister (did not provide age). One smoker living in home with child. Sister with
epilepsy, mother denies additional family history of disease or illness. Reports having outside
dog, no pets inside home. Home has public water source and propane heat source. Patient
reports playing basketball for the elementary school team, states on average has practice twice
weekly and games on Saturdays. Reports approximately one hour of physical activity such as
basketball, playing outside with friends, or riding his bicycle each evening when weather
permits. States watches TV and uses computer approximately one hour per day on weekdays,
and four hours per day on weekends. (Mother did not report type of home, employment status,
support systems, abuse, firearms in the home, cultural/religious beliefs, or environmental
exposure history.)

Immunization status: Current and up-to-date (last dates of immunizations were not included on
standardized history form).

Meds/Allergies: No known drug, food, latex, or metal allergies. Denies current prescription or
over-the-counter medications.

ROS:
General: Reports usual bedtime is around 2130 or 2200 and typically awakens at 0730 on school
mornings. Denies feeling tired during the day. Denies recent sickness.
HEENT: Denies difficulty seeing or hearing. Denies itching, burning, irritation, tenderness, or
drainage of eyes, ears, or nose, Denies throat soreness or trouble swallowing.

Skin: Denies cuts, scratches, bruising, rashes, or itching of skin.

Respiratory: Denies shortness of breath at rest or with activity, denies cough or congestion.

Cardio: Denies chest pain, tightness, or burning in chest.

GI: Denies sickness to stomach, vomiting, or diarrhea. Denies blood, pain, or difficulty
pooping. Reports having bowel movements approximately once daily, with last being yesterday
evening.

GU: Reports able to go to pee without difficulty, denies burning, pain, or blood.

Diet: 24 hour diet recall: Breakfast- pancakes, chocolate milk; Lunch- cheese sticks, peas/
vegetable blend, chocolate milk; Dinner- biscuit and gravy, sausage, water; Snack- none

Endocrine: Denies heat or cold intolerance, excessive thirst, hunger, or excessive peeing.

MS: Reports able to move all extremities without difficulty or pain.

Neuro: Denies dizziness, headaches, or sudden loss of speech.

Psych: Denies feelings of anxiousness, fear, sadness, or agitation.

(O) Vital signs T: 97.8F P: 84 R: 20 BP: 85/69 HT: 48.5 inches WT: 63 pounds (28.6 kg)
BMI: 18.8 Pain: Denies
Constitutional: Cooperative Caucasian male, appropriate dress for age and weather.
No grimacing, guarding, or acute signs of distress noted.

HEENT: Normocephalic, facial features symmetrical. Hair evenly distributed, no infestations,

flakes, abrasions, raised areas noted to scalp, eyebrows, eyelashes, or facial area. Red reflex
present bilaterally, light reflex present and equal bilaterally. Sclera white, conjunctiva pink with
no redness or drainage noted. Pupils equal, round, reactive to light, and accommodation. Extra
ocular movements intact. Denies tenderness of pinna or tragus bilaterally, tympanic membrane
visualized bilaterally, pearly grey in color, no drainage, bulging, or redness noted to membrane,
or outer canal, large amounts of dry appearing cerumen noted bilateral external ear canals.
Passed bilateral vision and hearing screenings without difficulty. Nasal passageways clear, no
redness, sores, deviated septum, polyps, or nasal drainage noted. Lips pink and moist, no
ulcerations or crustations noted. Oral cavity pink and moist, no ulcerations, dental caries, or
abnormalities noted, tongue midline, able to move freely without difficulty, no glossitis, palate
rises equally, uvula midline, tonsils visualized 2+ bilaterally, Trachea midline, thyroid palpated,
no goiter noted or tenderness reported. Lymphadenopathy noted to left posterior cervical chain
x3 nodes, approximately two mm each, non-tender with palpation. No additional
lymphadenopathies noted facial, neck, and supracervical lymph nodes, nodes are non-palpable
and non-tender.

Skin: Warm and dry. Intact, no lacerations, abrasions, ecchymosis, erythema, or rashes noted.

Respiratory: Lungs clear to auscultation in all lobes bilaterally, no stridor, wheezing, or crackles
noted. Lung expansion equal and symmetrical bilaterally. No clubbing of fingernail beds noted.

Cardio: Regular rate and rhythm, S1 and S2 noted. No murmurs noted.

GI: Normoactive bowel sounds noted. Abdomen soft and non-tender, non-distended, no
organomegally noted.

GU: 30+ urine protein, and negative urine glucose.

Endocrine: No hyperhidrosis or exophthalmos noted.

MS: Symmetrical, full range of motion noted to neck, back, bilateral shoulders, arms, fingers,
hips, knees, ankles, and toes. Muscle strength equal and strong bilaterally in shoulders, arms,
legs and feet.

Neuro: Alert and oriented to person, time, place, and event. Cranial nerves II-XII intact.

Psych: Appropriately interacts and answers questions, appropriate affect, no flat affect noted.
Does not appear anxious or in depressed mood, minimal fidgeting noted.

Other: Hemoglobin 10.3 mg/dl. Developmental screening: follows directions, backward heel to
toe without difficulty, able to dress self with assistance, able to tie shoes, and able to draw a
man/woman with at least eight parts.

(A)Dx: (include ICD 10 code - http://www.icd10data.com/ICD10CM/Codes ) (list as many

diagnoses as indicated)
Z00.12 Encounter for routine child health examination
D58.2 Other hemoglobinopathies
R80.9 Proteinuria, unspecified
R 59.0 Localized enlarged lymph nodes

Differentials:
1- 1 D50.9 Iron deficiency anemia, unspecified
2- D53.9 Nutritional anemia, unspecified
3- Z77.011 Contact with and (suspected) exposure to lead
(P) (Include costs of tests, medications, etc. can find resources for this at
http://www.nlm.nih.gov/services/drug_procedure_costs.html; www.epocrates.com,
http://www.goodrx.com)

Education/Anticipatory Guidance:
Always wear seat belt while in a vehicle, wear safety helmet while riding bicycle, never talk to
strangers, and need a plan for fire safety. Eat a well-balanced diet, limit soft drinks and sugary
drinks, and drink plenty of water. Take a bath or shower daily, brush teeth twice daily, floss at
least once daily (Yousey, 2017, pp. 111-113).

Follow-up instructions:
Follow up with Primary Care Physician regarding decreased hemoglobin levels. Should have
recheck of hemoglobin levels in approximately four to six weeks, to check the effectiveness of
multivitamin with iron on hemoglobin levels (Irwin & Kirchner, 2001). Stress the importance of
follow-up to evaluate cause of proteinuria (Gaylord, 2017, p. 929). Repeat urine dipstick test in
one month, if present do monthly recheck of urine for four to six months. If protein is persistent,
refer to a nephrologist (Gaylord, 2017, p. 929). Children with mild asymptomatic proteinuria
who have a normal first-morning specimen do not require extensive testing for kidney disease
but should be monitored annually (Gaylord, 2017, p. 929).

Other:
Recommended to begin multivitamin with iron daily. Avoid giving iron supplements with meals
or milk; vitamin C increases absorption (Giannetta & Kane, 2017, p. 644). Educate that iron
may cause stool to turn black in color (Giannetta & Kane, 2017, p. 644). Increase iron-rich
foods in diet, for example fortified breakfast cereals can be given as snacks (Giannetta & Kane,
2017, p. 644).
Iron deficiency anemia and lead exposure are the most common causes of decreased hemoglobin
levels in an infant and school-age child (Giannetta & Kane, 2017). Caution on methods of lead
exposure such as paint in houses older than 60 years old, and some toys made for children,
especially ones from China.
(Patient and family history are filled out on a form by parent [in this case mother] and sent back
to school giving permission for the child to have this examination, some of the information asked
in the SOAP is not part of the questionnaire and I do not have a way of obtaining this
information.)

Discuss how you addressed at least 3 NONPF competencies during this visit. (See NONPF
competency list)
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcorecom
petenciesfinal2012.pdf )

1. Scientific Foundation Competencies

According to Thomas et al. (2014) this competency can be met by critically analyzing data and
evidence for improving advanced nursing practice. I feel that I have met this competency
through analyzing laboratory values and developing an appropriate plan of care for this child
according to the recommendations through the literature.

2. Leadership Competencies
Thomas et al. (2014) states this competency is met through the demonstration of leadership that
uses critical and reflective thinking. I feel this competency has been met through using learned
advanced assessment skills and laboratory findings combined to make a diagnosis as well as
differential diagnoses and develop a plan of care according.

3. Technology and Information Literacy Competencies

This competency is met through coaching the patient and caregiver for positive behavioral
change (Thomas et al., 2014). I feel this competency was met through teaching of possible
causes of anemia and foods that are rich in iron, as well as possible ways of contacting lead and
items to be cautious about, such as toys made in China that have the potential to contain lead.
 References

Gaylord, N. M. (2017). Genitourinary disorders. In C. E. Burns, A. M. Dunn, M. A. Brady, N.

B. Starr, C. G. Blossser, & D. L. Garzon (Eds.) Pediatric Primary Care, 6th (ed.), (pp. 911-

945). St. Louis, MO: Elsevier.

Giannetta, T., & Kane, V. (2017). Hematologic disorders. In C. E. Burns, A. M. Dunn, M. A.

Brady, N. B. Starr, C. G. Blossser, & D. L. Garzon (Eds.) Pediatric Primary Care, 6th

(ed.), (pp. 626-659). St. Louis, MO: Elsevier.

Irwin, J. J., & Kirchner, J. T. (2001). Anemia in children. American Family Physician, 64(8),

1379-1387. Retrieved from: http://www.aafp.org/afp/2001/1015/p1379.html

Thomas, A. C., Crabtree, M. K., Delaney, K., Dumas, M. A., Kleinpell, R., Marfell, J. Wolf,

A. (2014). Nurse practitioner core competencies. The National Organization of Nurse

Practitioner Faculites. Retrieved from:

http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/npcor

ecompetenciesfinal2012.pdf

Yousey, Y. K. (2017). Developmental management of school-age children. In C. E. Burns, A. M.

Dunn, M. A. Brady, N. B. Starr, C. G. Blossser, & D. L. Garzon (Eds.) Pediatric Primary

Care, 6th (ed.), (pp. 101-120). St. Louis, MO: Elsevier.