NR 602 Sick Child SOAP Note Patient information:
G.G., 6yo, Asian, Female, Subjective:
“My fingers hurt.”
CC: bilateral index finger pain, fever, malaise, sore throat
HPI: 6yo female patient who was seen at the office two days ago with complaints of a sore throat and low-grade fever. During the last visit, the patient tested positive on the rapid strep test and was sent home on Amoxicillin.
The patient has returned with continuing fevers with a main complaint of bilateral second digit pain. The bothersome pain started yesterday and is now complaining of toe tenderness. Per the patient, her fingers hurt more than her feet or toes. Pt denies chills, cough, nasal congestion, trauma or being around anyone who was recently sick.
Mother states she had a fever last night of 101.1 F and was relieved with Tylenol. PMH:
■ Allergies: NONE
■ Current Medications: 10mL Liquid Tylenol PRN fever/pain, 10mL suspension Amoxicillin 250mg/5mL PO q12 hours, daily multi-vitamin
■ Immunization status: Up to date
■ Previous childhood illness: Innocent heart murmur, Otitis Media, Conjunctivitis
■ Surgeries: NONE
■ Hospitalizations: NONE ROS:
■ General: Mother reports fever, malaise, and decreased appetite. Denies chills, night sweats, unexplained weight loss or gain.
■ Eyes: Denies blurry vision, ocular pain, dry eyes, and ocular drainage.
■ Ears, Nose, Mouth, Throat: Reports sore throat, difficulty swallowing (painful to swallow).
Denies headaches, nasal drainage, and cough.
■ Cardiovascular: Denies activity intolerance, dyspnea, palpitations, and chest pain.
Mother states Cardiologist cleared her of her heart murmur and does not need to follow up. Pt has no restrictions with activity and plays soccer as a sport.
■ Respiratory: Denies cough, SOB, wheezing, difficulty breathing, and exposure to secondary smoke.
■ Gastrointestinal: Mother reports decreased appetite secondary to throat pain. Denies constipation, diarrhea, vomiting, and pain.
■ GU: Denies urgency, frequency, hematuria, foul odor and incontinence.
■ Musculoskeletal: Mother reports weakness x 2-3 days. Denies muscle pain, swelling, or stiffness.
■ Integumentary: Denies itching, rash, moles and wounds.
■ Neurological: Denies headache, numbness, memory difficulties, and seizures.
Objective
Physical Examination:
■ Constitutional: VS – Temp 99.6, BP 96/64, HR 77, RR 18, 02 sat 99%. Height – 47 inches (75th percentile), Weight- 45 lbs (50th percentile). BMI 14.3 (23.9 percentile). General appearance is well-developed. Pt appears bothered and is observed waving her hands due to finger pain/tenderness.
■ Eyes: White sclera, pink conjunctiva, Pupils are PERRL.
■ Ears: TM are intact. External appearance is normal. No lesions or drainage noted.
■ Nose: Nares patent. Septum is midline. No mucous, inflammation or lesions present.
■ Mouth: Mucous membranes are moist and pink. No lesions noted.
■ Throat: Bilateral tonsillar hypertrophy 3+ with exudate. Erythema.
■ Cardiovascular: S1, S2. Regular rate. Murmur was not heard at this visit. No gallops or rubs. Radial and pedal pulses are equal. No cyanosis or edema.
■ Respiratory: Lungs are clear. Breathing is even and unlabored.
■ Gastrointestinal: Normoactive sounds. Flat and soft. No guarding or masses present.
■ GU: No bladder distention or suprapubic pain.
■ Musculoskeletal: Pain to palpation on fingertips – most prominent on bilateral second digits. Tenderness on toes. Joint stability normal in all extremities.
■ Integumentary: Multiple scattered flat, red macules measuring 2mm on palms of hands and feet are noted. One vesicle is seen on the palmar side of her right, third digit. No open skin or drainage is present.
■ Neurological: CN are grossly intact.
Diagnostic tests:
■ Rapid Strep Result: Positive (2 days ago – 10/xx/2018)
■ Throat culture result: PENDING Additional data (not provided during visit):
After the patient was diagnosed, the patient’s mother called to inform the office that ABC Elementary School had four other students who presented with similar symptoms from mild to severe cases from the same class and grade level.
