Soap note pediatric

PATIENT INFORMATION

Name: CAL

Age: 15-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: NKA & NKDA. Denies latex allergy

Medication Intolerances:  None

Food Intolerances: None.

Current Medications: None

PMH: Unremarkable.

Immunizations:

Influenza November/2020.

Tdap dose Abril/2019.

HPV Completed with 2 doses 9 years ago.

Preventive Care: 6 months ago, within normal limits.

Hospitalizations/Surgeries.  None.

Family History: Unremarkable

Chronic Illnesses/Major traumas.  None

Social History: Lives with his parents. Patient is currently studying. The patient lives in a family house with his parents, who are kept active and both help the patient financial support.

Toxic habits. No Smoker.

Not use alcohol. Not use illicit drug. No Drink coffee.

Sexual Orientation: Heterosexual. Refers no sexual relations.

Anticonception in use. None.

Nutrition History: Maintains a balanced diet but he likes vegetable and meat. Practice physical exercise frequently at gym.

Prenatal background.

The patient is the only child, from a mother who pregnant at 30 years of age after a stable and functional marriage with the patient’s father, who has the following obstetric history: G1T1P0A0 L1. During the prenatal period she performed at least monthly follow-ups of the pregnancy in her OB consultation, there being no prenatal complications during this period.

Perinatal history.

Patient from a hospital delivery, physiological, without complications at 38.5 weeks gestation. Apgar 9/9

Postnatal Background.

Postnatal period without complications with clinical psychological evolution within normal limits.

Parent’s Current perception of Health: Excellent Good Fair Poor

Good.

Parent’ Social history: _X_ Married __Widowed __Single __ Divorced __Cohabitating Partner

Lives: _X__ Home ___Alone ___ Family ___Caretaker __ ACLF ___ SNF ___

Other: Smoke _None___

ETOH _None________

Recreational Drug Use _None.

 

Description of milestones according to developmental age.

Psychomotor development (fine and thick), within normal limits during different stages of childhood.

Language with normal development during the different stages of childhood.

Advanced school learning according to school report cards.

Adaptive social development during all stages of his childhood passed within normal limits, without psychological complications. Currently, he maintains a friendly relationship with his classmates without abnormal details to point out.

Food pattern.

He had an exclusive breastfeeding up to 6 months, with development of an adequate level of acceptance and food tolerance during the different stages of childhood.

Teeth development.

Within the limits of normality. Visit the Dentist once a year. He has received caries treatment 6 month ago. Make brushing his teeth after the three main meals.

Subjective Data:

Chief Complaint: “I have been having hives and itching in all my body”

Symptom analysis/HPI:

Patient is a 15 years old, alert and aware, male and Hispanic white, who is visiting the Angel E Rico office and refers skin lesions for the last two weeks. The patient states, “I have been having hives and itching in all my body” and describes that skin lesions appear and disappear spontaneously, and they don’t last more than 2 days with different size and shape. Denies pain (0/10 no pain scale). Denies Shortness of breath. He refers is not taking any medications. His family history is unremarkable. The patient has no history of being hospitalized. No surgical history. Patient never received blood transfusion.

Review of Systems (ROS)

CONSTITUTIONAL. Not Fever. Denies weakness. Denies nighttime sweats. Denies weight loss and loss of appetite.

NEUROLOGIC: Denies paralysis, tingling, numbness. Denies syncope, seizures. Denies changes in LOC. Denies photophobia.

HEENT:

Head: Denies any head injury or change in LOC. Denies headache.

Ears: Denies Ear pain, hearing loss, ringing in ears. Denies drainage.

Nose/ Mouth/Throat: Denies sinus problems. Denies dysphagia. Denies problems swallowing, nose bleeds or discharge.

Eyes. Denies secretions. Denies any changes in vision, diplopia, or blurred vision.

RESPIRATORY: Denies cough. Denies shortness of breath. Denies Hemoptysis.

CARDIOVASCULAR: Denies cardiovascular issue and chest pain. No edema. Heart rate feeling within normal limits. No orthopnea or paroxysmal nocturnal dyspnea. No chest pain. No orthopnea or paroxysmal nocturnal dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. Denies historic or recent STD exposure.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. Denies weakness. Denies joint swelling and stiffness.

SKIN: Skin: The patient refers skin lesions (Hives) that appear and disappear spontaneously, accompanied by pruritus for two weeks (See HPI). No injuries, traumas, ecchymosis, or bruising.

Denies bleeding and skin discolorations.

BREAST.

Denies abnormal growth on breast.

HEME/LYMPH/ENDO: Denies bruising, night sweats, swollen glands.

PSYCHIATRIC: Denies presence of psychiatric illness. Denies depression. Denies insomnia. .

Objective Data:

VITAL SIGNS: Temperature: 98.4 F °F, Pulse: 71bpm, BP: 114/74mmHg, RR 16rpm, PO2-100% on room air, Ht- 68.3 in. (173.5 cm), Wt. 116 lb., 50th percentile Pain: 0/10.

GENERAL APPREARANCE: White Hispanic boy, with normal posture. Facie conserved. Alert and oriented X3; answering the medical interview properly.

NEUROLOGIC: Alert, Physical examination of cranial nerves without obvious alterations to the inspection and physical examination. Oriented to person, place, and time. Walk or stand conserved to gait and reach posture erect. Reflexes bilateral conserved. Bilaterally Extremities Strength 5/5. Speech clear. CNII-XII grossly intact.

HEENT: Head: Normocephalic, atraumatic, symmetric. Maxillary sinuses no tenderness. Eyes: Not conjunctival hyperemia. Not secretions. Not bilateral edema in the eyes. No icterus. Visual acuity within normal limits. Extraocular eye movements intact. No nystagmus noted. Pupils PERRLA. Not papilledema. Ears: Bilateral canals patent. Not swelling. Not drainage. Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, non-inflamed and characteristics within normal limits. Nasal (both nares) pink, moist and intact. Not bleeding noted. No congestion. Oral mucosa. Dry and pink. Neck: Supple. Full ROM. No LAD (Lymphadenopathy or adenopathy), Thyroid without obvious alterations to the inspection and physical examination. No JVD (Jugular venous distension). Not bruit palpated or auscultated. Throat. Oropharynx without obvious alterations to the inspection and physical examination. No erythema. Not edema. No exudate. Not bleeding noted. . Complete natural teeth in the oral cavity. Lids non-remarkable and appropriate for race.

CARDIOVASCULAR: S1, S2 without obvious alterations to physical examination. Normal rhythm. No extra heart sounds. Capillary refill more than 2 sec. Not bruit auscultated. Bilateral peripheral pulses present and without obvious alterations to physical examination.

RESPIRATORY: Conserved thoracic expansibility. Symmetric chest walls. No dyspnea or use of accessory muscles observed. Respirations regular and unlabored; Normal respiratory sounds in both lung fields to auscultation bilaterally. Not clubbing. No egophony, whispered pectoriloquy or tactile fremitus on palpation.

GASTROINTESTINAL: Abdomen soft, not distended, painful to the superficial and deep palpation in epigastric. Bowel sounds present in all four quadrants. Maneuver fist negative percussion. Not Abdominal pain with rebound. Not guarding. Non hepatomegaly. Spleen not palpable. No bruits over renal and aorta arteries. No mass or hernia observed or palpated. No spider veins.

MUSKULOSKELETAL: Full ROM seen in upper and lower extremities during examination.

Preserved ambulation and gait without obvious alterations to physical examination. Superficial and deep sensory conserved in the extremities. Deep tendon reflexes Conserved bilaterally. No stiffness.

INTEGUMENTARY: Skin within normal limits for age and race. No cyanosis or jaundice. The patient has weals, well defined raised lesions with a smooth surface. They are red or white, surrounded by a red or white flare irregularly distributed in the trunk and upper extremities, without scratching sequelae. Skin Smooth and Dry. Clean and intact. Not turgor. Nails without obvious alterations. Hair with proper implantation and distribution.

GENITOURINARY. Maneuver fist negative percussion. Not Costovertebral angle (CVA) tenderness. Anterior and posterior pielorenoureteral points (PPRU) without obvious alterations to physical examination.

External genitalia with appearance without obvious alterations to physical examination. Tanner stage 5. No ulcerated lesions noted in the inspection. Not Lymph nodes palpable. Urethral orifice in proper position and good appearance. No presence of a bladder balloon.

PSYCHIATRIC.

Alert and oriented X3. Dressed in appropriate and clean clothes. Maintains eye contact. Answers questions appropriately. Adequate behavior during the physical examination. ASSESSMENT:

Main Diagnosis:

Urticaria (ICD10 H50.9): Urticaria results from the release of histamine, bradykinin, kallikrein, and other vasoactive substances from mast cells and basophils in the superficial dermis, resulting in intradermal edema caused by capillary and venous vasodilation and occasionally caused by leukocyte infiltration. Urticaria is classified as acute (< 6 weeks) or chronic (> 6 weeks); acute cases (70%) are more common than chronic (30%). Acute urticaria is nearly always due to some defined exposure to a drug or physical stimulus or an acute infectious illness. Most chronic urticaria is idiopathic. The next most common cause is an autoimmune disorder. Skin examination should note the presence and distribution of urticarial lesions as well as any cutaneous ulceration. Urticarial lesions usually appear as well-demarcated transient swellings involving the dermis. These swellings are typically red and vary in size from pinprick to covering wide areas. Some lesions can be very large. In this case the diagnosis is based on the clinical symptoms associated with Pink skin lesions, of different sizes, in the form of soaps, irregularly distributed in the trunk and upper extremities, without scratching sequelae. (Joo, 2019).

Differential diagnosis:

· Angioedema (ICD10 T78.3). Angioedema is edema of the deep dermis and subcutaneous tissues. It is usually an acute mast cell – mediated reaction caused by exposure to drug, venom, dietary, pollen, or animal dander allergens. Patients who have angioedema involving the oropharynx or any involvement of the airway, so this condition can be ruled out. (Joo, 2019).

· Erythema Multiforme. (ICD10 51.9). Erythema multiforme (EM) is an inflammatory reaction, characterized by target or iris skin lesions. Oral mucosa may be involved. Erythema multiforme usually occurs as a reaction to an infectious agent such as herpes simplex virus or mycoplasma but may be a reaction to a drug. Erythema multiforme manifests as the sudden onset of asymptomatic, erythematous macules, papules, wheals, vesicles, bullae, or a combination on the distal extremities (often including palms and soles) and face. The classic lesion is annular with a violaceous center and pink halo separated by a pale ring (target or iris lesion). Distribution is symmetric and centripetal; spread to the trunk is common. Some patients have itching, so this condition can be ruled out. (Codina Leik, 2018).

· Contact dermatitis (ICD10 L25.9). Contact dermatitis is acute inflammation of the skin caused by irritants or allergens. The primary symptom is pruritus. Skin changes range from erythema to blistering and ulceration, often on or near the hands but occurring on any exposed skin surface. Changes often occur in a pattern, distribution, or combination that suggests a specific exposure, such as linear streaking on an arm or leg (eg, due to brushing against poison ivy) or circumferential erythema (under a wristwatch or waistband). Linear streaks are almost always indicative of an external allergen or irritant, so this condition can be ruled out. (Codina Leik, 2018).

PLAN:

According to the guidelines for Urticaria the diagnosis is clinical, based on the history, symptoms and clinical signs. Uncomplicated Urticaria, complementary tests need to be performed to diagnose possible underlying cause. Currently, the patient has indication of performing test. (Joo, 2019).

Test ordered.

Blood count, blood smear, microscopic exam w/o manual differential WBC count.

Allergen specific IGE, quantitative/ semiquantitative, crude allergen extract, each.

Comprehensive metabolic panel.

Stool sample.

Pharmacological treatment:

Uncomplicated Urticaria does not require hospitalization, the initial empirical treatment is indicated with antihistamines. Antihistamines remain the mainstay of treatment. They must be taken on a regular basis, rather than as needed. (Codina Leik, 2018).

Therefore, the pharmacological treatment to be performed is.

· Cetirizine 10 mg once / day for 7 days.

· Hydrocortisone (cream) in skin lesions two time a day.

Non-Pharmacologic treatment:

It is aimed at developing general and support measures that facilitate a faster recovery and prevention of a new and recurrent Urticaria. (Joo, 2019).

· Rest.

· Perform careful hand washing.

· Use cold compresses.

· Taking cool baths.

· Avoid hot water.

· Avoid scratching the skin.

· Wearing loose clothing.

· Maintain proper skin hygiene.

Education

These measures are aimed at decrease recurrence of Urticaria. (Joo, 2019).

· Perform frequent hand washes.

· Change towels, and body cloths daily during treatment.

· Maintain a healthy nutrition.

· Perform the complete treatment indicated by the doctor.

· Do not take or use for the skin any herbal product without consulting your doctor.

· If the symptoms do not improve after 48-72 hours seek medical help immediately.

· Instruction about medication intake compliance.

· Make a balanced and balanced diet with adequate nutrients.

· Symptoms (Pruritic) and lesions take up to 3 weeks to resolve despite killing of the mites

Patient was educated on course of Urticaria, as well as red flag signs and symptoms of severe Urticaria (such as Angioedema (swelling of the face, lips, or tongue), Stridor, wheezing, or other respiratory distress, Hyperpigmented lesions, ulcers, or urticaria that persist> 48 hours

Signs of systemic illness (e.g., fever, lymphadenopathy, jaundice, cachexia), which could indicate the need to attend the ED. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

At this time will be treated as an outpatient at home with follow-up in the next 48-72 hours. (Codina Leik, 2018).

· After 48or 72 hours if you do not observe clinical improvement immediately seek medical assistance or return to consultation.

· If there is clinical improvement, return to school after 3 days.

· If clinical improvement after 72 hours, return to medical consultation at 7 days for analysis of the indicated tests.

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