Expert answer:SOAP GI female
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Pediatric SOAP Note
Pediatric Gastro Esophageal Reflux SOAP Note
Pediatric SOAP Note
Name: K J
Sex: FEMALE
Date: 25st September 2017
AGE: One-year-old
DOB :21st July 2016
Place of Birth: Albuquerque –New Mexico State
SUBJECTIVE
Historian: Adoptive mother
Present Concerns/CC:
“The baby is experiencing abnormal spitting.”
“She cries for a long time exceeding more than three hours.”
She is having trouble or gagging when swallowing.”
“Prevalence of wheezing, vomiting and appears malnutrition.”
“She is losing weight.”
“She is refusing to feed.”
Child Profile:
Commented [KECH1]: Missing component(s), please
review the document Elements of a Great SOAP note.
The adoptive mom of the baby has had the toddler for a period of four months now and claims the
baby has been active and feeding well. For the last three, she has lost weight, and the prevalence of
wheezing and problem of swallowing within the throat. Some of the safety practices include sitting
Commented [KECH2]: HPI
the baby upright for around 20 minutes after feeding, stopping around three ounces to burp the
infant and sleeping the baby in an inclined position to reduce some discomfort. The developmental
Commented [KECH3]: These are not “safety practices”
process has been normal. Since the manifestation of the symptoms, the baby has been losing
weight.
Commented [KECH4]: HPI
Pediatric SOAP Note
HPI:
The baby was delivered through premature birth, this is all the adoptive mother knows. She has never been
seriously ill. She is experiencing pain within the abdominal area. She has never had any significant surgeries.
Some of the pertinent positives include continued crying for more than three hours, wheezing, vomiting and
poor feeding. Some of the pertinent negatives include abdominal pain and loss of body weight. Some of the
Commented [KECH5]: How is this detected?
Commented [KECH6]: PMH
Commented [KECH7]: Why do you have pertinent
positives/negatives in the HPI?
aggravating factors include vomiting immediately after feeding, continuous crying after eating
Medications:
No known home medications or prior use drugs.
PMH: No noted past medical history this child was full term vagina birth
Allergies:
The infant is allergic to fur, pollen, sulfa, and cow milk
Medication Intolerances:
K. has sulfa antibiotic intolerance
Chronic Illnesses/Major traumas:
The client has not had any chronic illnesses of significant trauma
Hospitalizations/Surgeries:
She has never been hospitalized
Immunizations:
The patient has received the following vaccines DTaP (diphtheria, tetanus, and pertussis),
Prevnar, IPV (inactivated polio vaccine), HIB (Haemophilus influenza type B) and Hepatitis B
vaccine.
Commented [KECH8]: When? How many doses?
Pediatric SOAP Note
Family History
The baby does not have siblings as she is the only child in her adoptive family. Her foster dad is healthy
although has been having asthmatic attacks occasionally. The health status of the foster mother is okay. In the
rest of the family, there are no cases of cardiac problems, diabetes or any chronic illness.
Since she is adopted her family history is unknown
Social History
The patient is a one-year-old girl. There is no occupational history, marital status, educational level or a
history of tobacco or marijuana abuse. The parents of the infant are financially good, giving the infant a
Commented [KECH9]: Do you know that for sure if she is
adopted? You can say that she “Doesn’t have any adoptive
siblings.” Do you know if she has any biological siblings?
Commented [KECH10]: This family history concerns
biological family members. The last statement would have
sufficed.
Commented [KECH11]: Who does the child live with
exactly? Are there any exposures to anything? What are the
safety measures of the home?
Commented [KECH12]: ??????
Commented [KECH13]: Should there by for a 1 yo?
clean and safe house. The neighborhood is not very safe as there have been cases of gun shots
occasionally. The child is not exposed to daycare.
ROS
General
Cardiovascular
The infant is shedding weight with difficulty in
Mother states, “There are no cases of edema, PND or
feeding. She looks malnutrition, according to
orthopnea. No chest pains”
Commented [KECH14]: The ROS (and exam) for an
episodic visit needs to be focused, not comprehensive.
Commented [KECH15]: Not an appropriate term for
“loosing” weight.
Commented [KECH16]: Grammar
Commented [KECH17]: Not age appropriate
mom
Skin
Respiratory
The infant does not have any bruises. No moles,
There is the prevalence of wheezing. The baby breathes
lesions or presence of discolorations, according
with difficulty. She does not have a history of either
to mom.
tuberculosis or pneumonia, according to mom.
Commented [KECH18]: How is this relevant to the CC?
Pediatric SOAP Note
Eyes
Gastrointestinal
Mom states, “the baby does not seem to have
Mom states, she has noted blood spots in the stool.
any visual changes orb prevalence of blurred
Her appetite seems low as she is refusing to eat via
visions”.
mom.
Ears
Genitourinary/Gynecological
“No cases of discharge within the ears, pain, heat “No history of any case regarding the Genitourinary/
loss”, states mom
gynecological problems”, according to mom
Nose/Mouth/Throat
Musculoskeletal
“No cases of bleeding from the nose. There are
“No cases of Musculoskeletal problems. Swellings
little sores which can be noted within the throat.
cannot be seen the baby. The neck doesn’t seem
No cases of bleeding gums. The throat most be
stiff”, per mom
painful”, per mom
Breast
Neurological
No complications, via mom
“The child has never experienced paralysis, black
Commented [KECH19]: How is this relevant to the CC?
Commented [KECH20]: How is this relevant to the CC?
Commented [KECH21]: How is this relevant to the CC?
Commented [KECH22]: The ROS is not for “history of”
but current complaints.
Commented [KECH23]: How is this relevant to the CC?
Commented [KECH24]: How is this relevant to the CC?
Commented [KECH25]: How is this relevant to the CC?
Commented [KECH26]: How is this relevant to the CC?
out spells or seizures”, according to mom
Heme/Lymph/Endo
Psychiatric
Mom states, “The patient is HIV negative with
No psychiatric complications noted, via mom
Commented [KECH27]: How is this relevant to the CC?
Commented [KECH28]: How is this relevant to the CC?
no history of any blood transfusion. She is
intolerant to heat”.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Head circumference
is 18cm= 72.6 percentile Please refer to growth chart in separate attachment
Commented [KECH29]: This information should not be
here. Good growth curves attached.
Pediatric SOAP Note
BP under 3
Weight
Temp
9.07 Kg=57.9%
36.5°C
Height
Pulse
Resp
75 cm=65.5%
120 beats per minute
24 breaths per minute
General
The girl looks well-kept as if she is not malnutrition.
Commented [KECH30]: I don’t understand what this
sentence means.
The parent children interaction is positive.
The child looks neatly dressed.
she does seem oriented or alert
Skin
Commented [KECH31]: How is this relevant to the CC?
The skin looks clean and warm with no lesions or rashes
HEENT
Commented [KECH32]: How is this relevant to the CC?
There are no notable lesions on the head. No trauma incidences. The distribution of hair is normal.
The ear canals are intact with no infections. Lack of occipital nodes within the neck and the nose
mucosa does not appear pink. The games are in good health
H-Head circumference is 18cm, her has a round head the frontal soft spot is not yet closed.
E-Bilaterally her ears look bulgy fleshy pearl free of pus, noted fluid
Commented [KECH33]: Then what does it look like?
Commented [KECH34]: What?
Commented [KECH35]: It is not called “frontal.” What is
the approximate size?
Commented [KECH36]: What?
E- bilaterally both eyes are free of sties, redness, drainage and both have a red reflex noted
N- Scant amounts of mucus noted bilateral nares clear in color and thin in texture
T- Her throat does not appear red, the dentition is fine, there are no lesions or exudates. The oral mucosa
is pink.
P- Mucosa non-inflamed, no tonsillar hypertrophy or exudate.
Commented [KECH37]: This does not describe “mucus.”
What is the proper medical term for this?
Pediatric SOAP Note
Cardiovascular
The rhythm is normal with regular S1 and S2 palpitations. No cases of edema. The rate of capillary
refilling is 3 minutes.
Commented [KECH38]: ????
Commented [KECH39]: Where?
Respiratory
The chest is symmetric. There are wheezing sounds. There is difficulty in breathing with an abnormal
rhythm. The lung auscultations don’t seem to be clear. Apnea is present
Commented [KECH40]: What kind of wheezing sound?
Exactly where?
Commented [KECH41]: I don’t know exactly what you’re
trying to describe. You need to use professional
terminology and be more descriptive.
Gastrointestinal
No abdominal obese. Red spot on the stool is present. There is suggested abdominal pain using the face
pain scale
Breast
Commented [KECH42]: What?
Commented [KECH43]: You observed a “red spot” on the
stool? You need to use professional terms.
Commented [KECH44]: Hmmmm. I don’t know about
this.
Not performed
Genitourinary
No pain or burning sensation during urination according to the face scale of pain. No any kind of
Commented [KECH45]: You cannot say this. Did you
watch the pt urinate?
unusual discharge from the vagina. No pubic hair. No signs of any kind of bleeding around the rectum
Commented [KECH46]: Grammar
or hemorrhoids visible. The lower belly is lesser full
Commented [KECH47]: What?
Pediatric SOAP Note
Musculoskeletal
Neurological
The child is yet to maintain full body balance. She does not have an erect posture
Commented [KECH48]: How is this relevant to the CC?
Commented [KECH49]: What?
Psychiatric
Commented [KECH50]: How is this relevant to the CC?
The patient does look alert and oriented. She maintains an eye contact with her mother. She is however
Commented [KECH51]: How can a 1 yo “looked
oriented”?
neatly dressed
In-house Lab Tests–document tests (results
or pending)
1. Esophageal pH- uses reflux index to quantify the acidic reflux. Results were positive
2. Esophageal manometry – supports the finding of excessive stomach acid
3. Intraluminal esophageal electrical impedance- Abnormal nonacid and acid reflux
Pediatric/Adolescent Assessment Tools
Some of the pediatric assessment tools include
Episodic visit
Diagnosis
Pediatric SOAP Note
differential diagnoses with ICD-10codes. (IncludesPrimarydxand2differentials)
1.
P78.83 Pediatric Gastro Esophageal Reflux- Pertinent positives include vomiting, extended
cry, and weight loss. Pertinent negative is abdominal pain and wheezing
2.
Q40.1 congenital hiatus hernia-pertinent positives include faster heart rate and the lower belly
being lesser full while pertinent negatives include lack of bluish color within the skin
3.
K52.0 gastroenteritis- some of the pertinent positives include omitting and abdominal pains.
The pertinent negatives are lack or fever or diarrhea symptoms (Patient Platform Limited, 2017)
Primary diagnosis
P78.83 Pediatric Gastro Esophageal Reflux (Schwarz, 2016)
The diagnosis was based on the presentation of the patient. Lack of fever. No noted blisters as
reported by mom. Positive Esophageal pH- uses reflux index to quantify the acidic reflux. Results
were positive
Commented [KECH52]: Good
Commented [KECH53]: You did not address the
respiratory issues at all.
Pediatric SOAP Note
PLAN including educationTreatment plan
Nexium 5mg/5ml one teaspoon by mouth daily dispense 160ml bottle 0 refills (BAIRD, 2015)
✓
Vaccines administered today
Commented [KECH54]: Weight based dose
recommendation?
Commented [KECH55]: APA error(s)
Measles, Mumps, and Rubella (MMR) Vaccine (INJECTION)
Varicella (IM)
✓
Laboratory tests ordered
H pylori serum to be done at the lab at Webster county hospital
CBC with be done for baseline and to r/o infection
✓
Diagnostic tests ordered
esophageal pH monitoring
Future considerations
EGD to r/o abnormalities of the esophagus and upper stomach (KOVACIC, 2014,
p.12) if the child has not improved by >18 to check for web, strictures, and or
Commented [KECH56]: APA error(s)
obstruction.
✓
Patient education including preventive care and anticipatory guidance
a) Avoid use of positional management techniques to treat Gastro Esophageal
Reflux.
b) Ensure proper breastfeeding exercise are maintained when feeding the infant
Commented [KECH57]: What!?!?!?!? How is this
applicable to this patient?
c) Provide smaller but more frequent feeds
d) Add rice cereal mixture to the baby’s formula or stored breast milk
✓
Non-medication treatments
Commented [KECH58]: This child is 1 yo and should not
be on “baby’s formula” and since she is adopted, I highly
doubt she is breastfeeding. Your education should be
appropriate for the patient!
Ensure the child is not overeating and sits up for at least 45 min after meals to ensure
proper digestion
Changes in feeding
Follow-up appointment
Visit after 2 weeks for Hep A vaccine. Check weight and esophagus PH
Commented [KECH59]: Why wasn’t it given today?
Pediatric SOAP Note
Commented [KECH60]: No self-assessment
References
Commented [KECH61]: APA error(s)
BAIRD , D. (2015, October 15). Diagnosis and Treatment of Gastroesophageal Reflux in Infants and
Commented [KECH62]: APA error(s)
Children – American Family Physician. Retrieved from
http://www.aafp.org/afp/2015/1015/p705.html#sec-4
Commented [KECH63]: APA error(s)
KOVACIC, K. (2014). Pediatric gastroesophageal reflux disease. kovacic_reflux, 12. Retrieved from
Commented [KECH64]: APA error(s)
https://www.chw.org/-/media/images/for-medical-professionals/pediatric-rounds2014/kovacic_reflux.pdf?la=en
Commented [KECH65]: APA error(s)
Patient Platform Limited. (2017). Childhood Gastro-esophageal Reflux. Reflux esophagitis | Patient.
Retrieved from https://patient.info/doctor/childhood-gastro-oesophageal-reflux-pro
Schwarz, S. (2016, March 28). Pediatric Gastroesophageal Reflux: Practice Essentials, Background,
Commented [KECH66]: APA error(s)
Etiology and Pathophysiology . Retrieved from http://emedicine. medscape.com/article/930029overview
Commented [KECH67]: Not an acceptable source
Subjective
Information:
“CC”,
HPI :OPQRST
S
NEEDS
IMPROVEMENT
(.5 points)
COMPETENT
(1.5 points)
EXCELLENT
(2 points)
Less than 50% of
pertinent information is
addressed; or is
grossly incomplete
and/or inaccurate.
Poorly organized and/or
limited summary of
pertinent information
(50%-80%); information
other than “S” provided.
Well organized;
partial but accurate
summary of pertinent
information (>80%).
Less than 50% of
pertinent information is
addressed; or is
grossly incomplete
and/or inaccurate.
Poorly organized and/or
limited summary of
pertinent information
(50%-80%); information
other than “O” provided.
Partial but accurate
summary of pertinent
information (>80%).
Complete and concise
summary of pertinent
information.
Less than 50% of
diagnoses are listed; or
main diagnosis missed;
or differential diagnosis
not prioritized and/or
identified nonexistent
problems.
Some diagnoses are
identified (50%-80%);
incomplete or
inappropriate diagnosis
prioritization; includes
nonexistent diagnosis or
extraneous information
included.
Most diagnosis are
identified and
rationally prioritized,
including the “main”
diagnosis for the
case (>80%).
Complete differential
diagnosis generated and
rationally prioritized; no
extraneous information or
issues listed.
Score
NOT
ACCEPTABLE
(0 points)
Maximum
Points
Pediatric SOAP Note
1
2
1.5
2
2
2
Complete and concise
summary of pertinent
information.
IF f/u: health status since
last visit, response to
therapies.
PMH, PSH, FH, ROS
complete
Objective
Information:
O
Complete physical exam
with critical elements
related to subjective
Assessment:
Minimum of 3
differentials
supported by S + O
data
A
Final diagnosis noted
and optimal and
thorough subjective
and objective
assessment is
Comments
Pediatric SOAP Note
Plan:
Diagnostic
tests/therapies/followup, Patient education,
health promotion.
Medications listed with
P
Self Assessment &
Clinical Guidelines
dosage/SE/Education/
Analyze quality and
relevance of S + O data
and the evidence for
diagnosis. Use of
clinical evidence based
reasoning & literature
in designing plan of
care, compare to plan
of care implemented.
Less than 50% of
diagnosis have an
appropriate and
complete treatment
plan.
Partially complete and/or
inappropriate for a few
identified diagnosis
(50%-80%); information
other than “P” provided.
Less than 50% of
diagnosis include
appropriate
counseling, monitoring,
referral and/or followup plan.
Patient education points,
monitoring parameters,
follow-up plan and
referral plan (where
applicable) for a few
identified problems (50%80%).
Did not analyze data
gathered.
Partially complete and/or
inappropriate use of data
in assessment data.
Did not use clinical
evidenced based
reasoning.
Did not identify
literature or treatment
guidelines to guide
plan of care.
Partially identified clinical
evidenced based
reasoning.
Partially identified
literature or treatment
guidelines to guide plan
of care.
Mostly complete and
appropriate for each
identified problem
(>80%).
Patient education
points, monitoring
parameters, followup plan and referral
plan (where
applicable) for >80%
of identified
problems.
Mostly complete
and appropriate
analysis of data in
assessment.
General use
of clinical
based
reasoning.
Identified literature in
most part and
clinical guidelines in
plan of care
development
identified.
Specific, appropriate and
justified
recommendations
(including drug name,
strength, route,
frequency, and duration
of therapy) for each
identified problem.
Analyze quality and
relevance of S + O
data—supported by
evidence and clinical
guidelines. Identify
needed but missing S +
O data. Describe what
you would do differently
and why.
2
0.5 2
Use of clinical evidence
based reasoning &
literature in designing
plan of care, compare to
the actual plan of care
implemented
Sub-Total:
Grammar,
Format & APA
1.5
Specific patient education
points, monitoring
parameters, follow-up
plan and (where
applicable) referral plan
for each identified
problem.
•
Utilizes SU SOAP Template
•
APA citations are utilized as indicated
•
Format: length does not exceed 1 page (10-point font; 1-inch margins).
If directions are not followed, deduct two points from final score.
In addition, follow SU deductions for late submissions.
6.5
Subtract points for
grammar, Format, & APA
as indicated
-0.5
•
Final Total
6
10
Pediatric SOAP Note
…
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