South University Family Nurse Practitioner

Pediatric EPISODIC SOAP Note Template

Student’s Name: Date:

Hephzibah Tranquilan 2/2/2021

Patient / Client initials: Age:

E.S. 9 years old

Gender: Ethnicity:
Female
Mexican American
Historian:
Mother and patient are good historian.
They presented to the clinic well-mannered and
properly dressed.

SUBJECTIVE DATA

Chief Complaint The mother said that “my daughter went to her school dance yesterday and ever
(CC) since she went home, she has been itching all over her body.” The patient said that
“I am itchy, and I have been trying to not scratch it.’
History of
Present Illness The patient is presented to the clinic as having itchy spots all over her mouth, hands
(HPI) and feet. The mother reported that the patient went to Dance class yesterday and
they were having dance exercises on the mat. The patient developed one itchy spot
on her left elbow, and it spread through her mouth, hands, and feet. She went to her
dance class yesterday and she have been itching It. Her mother said that the patient
did not really have a good sleep last night as the patient was having discomfort. The
patient denies any feeling of chills, fever, and pain. However, she reported the
feeling of discomfort because of the itchiness, when asked what relives the
discomfort, she said that when she took a shower, she did not feel being itchy.

.
Past Medical The patient has been a patient of the pediatric clinic since she was a newborn. She
History (PMH) does not have record of hospitalizations nor any known major medical issues.

She had her knees scraped last year because she went in a sport team but that is
the only major medical event that had happened to the patient.

Family History The mother has no known medical issues aside from that she admitted that she is a
5 pack years cigarette smoker. The father was not present during the consultation.
The mother is vague upon giving the history of the father side.
Social History The patient lives with her mother. Her parents have been divorced since she was 5
years old. They do not have pets in the house. She is the only child of her mother
and they live with her mother’s boyfriend.

The mother reported that the patient has been in the honor roll since she was in
kindergarten and that she is always doing something that involves school
extracurricular activities.
The mother said that she gave Benadryl to her daughter to keep her from itching
Medication however it makes the patient sleepy.
Reconciliation /

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Review The patient has no known drug allergy.

Allergies
No known drug allergies
Immunizations
The patient is up to date with her immunizations.

Health The patient is up to date with her immunizations and she is also active with after school
Promotion/ extracurricular activities.
Health
Maintenance

Constitutional Symptoms:

Review of The patient denies that she has any fever, change in activity level, or night sweats.
Systems (ROS)
Eyes:

The patient denies any vision problems, tics, strabismus nor nystagmus experienced by the
baby.

Head:
The patient denies experiencing any headaches, she denies any discomfort nor itching on her
scalp.

Ears, Nose, Mouth, Throat:

The patient denies any ringing on her ears, nausea, any nasal discharge, she did reported that
she has throat pain that made her “scared” of not eating because it hurst her throat.

Teeth:
The patient denies any tooth ache. She reported that she brushes her teeth twice a day. Once in
the morning and another before going to sleep.

Cardio/Respiratory:
The patient said she is not experiencing any dyspnea, cough, wheezing or cyanosis episodes.

Genitourinary:
The patient denies any rashes, itching on her genitourinary area.

Gastrointestinal:
The patient reported that she has not had any diarrhea, constipation or experience any
abdominal pain or discomfort.

Neuromuscular:
The patient said that she does not have any convulsions nor spasms.

Endocrine:
The patient said that she does not have any disturbances in growth, she has no appetite
problem. The mother reported that her daughter is a picky eater. The patient denies feeling any
cold or hot all throughout the day.

Hematologic/Integumentary:
The patient admitted that she has been itching her left elbow and it spread on her mouth and
feet.

Rheumatologic:
The patient denies any problems with her joints. She reported that she does not have any
swollen, pain nor stiffness noted around her body parts.

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 Objective

Vital Signs Vital Signs:

Temperature: 97.8 (Temporal) Blood Pressure: 100/64

O2 Saturation: 100% Weight: 61 lbs.
Respiratory Rate: 20 Height: 52 inches
Heart Rate: 78 bpm
Clinical Growth chart Percentile: The patient is on the 50% percentile on her weight and
growth chart.

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 Systems/Body Areas of Physical Examination

General appearance:
E.S is active and energetic as evidenced by her extra-curricular activities. She appears well kept
and is closely bonded with her mother, looking at her occasionally for comfort. Her clothes
appear clean.
Physical
Examination Skin:
Texture and appearance are within normal range, no pigmentation noted. Good skin turgor
(PE) especially of the calf muscles and skin over the abdomen. No Mongolian spots noted. Rashes
noted around bilateral elbows, feet and hands.

HEENT:

Head: Normocephalic, no lesions.

Eyes: Symmetric with normal extraocular movements. Pupils 4 to 5 mm constricting.
Ears: Normal Pinna noted. No external abnormalities noted. Normal external canals and
tympanic membranes intact.
Nose: Normal nares; septum midline.
Throat: tonsils are normal in size, no exudate, white blisters noted on the sound of the mouth,
appropriate color of tongue noted.

Neck:
Supple and no lymphadenopathy noted. Thyroid size is appropriate to age.

Pulmonary:
Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi.

Cardiovascular:
Regular rate and rhythm, S1S2 present with no murmurs appreciated, rubs, or gallops, good
pulses.

Respiratory:
Chest symmetric and clear to auscultation anteriorly and posteriorly.

Abdominal:
Positive bowel sound in all 4 quadrants, soft, nontender, and nondistended.

Skin:
No bruising. Positive: small reddened macular erythematous papules noted on the bilateral
elbow and hands, mouth and feet.

Musculoskeletal:
No pain to palpation. Active and passive ROM within normal limits with some gait dysfunction,
Strength 4 on bilateral peripheral lower extremities.

Spine and Back:

Posture is appropriate to age, no rigidity noted. No pilonidal dimple nor cyst noted.

Neurologic:
Intelligence is appropriate to age, can recognize parents, has normal flexion, sucking, rooting
and Moro reflex. Anterior and posterior fontanelles are open, not distended nor sunken.

Assessment
Diagnosis
Diagnosis (Dx)

Hand, Foot and Mouth Disease ICD 10 074.3

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 Hand, Foot and Mouth Disease is common in children under 5 years old but anyone can get it.
The illness is usually not serious, but it is very contagious. It spreads quickly at school and day
care centers. It is often confused with foot -and-mouth disease (also called hoof-and mouth
disease), which affects cows, sheep, and pigs. Humans do not get the animal disease, and
animals do not get the human disease (CDC, 2021).

Differential Diagnosis (DDX)

Herpes Simplex Virus ICD 10 B00.82

Herpes viruses or herpes viruses are double stranded DNA viruses with icosahedral symmetry,
belonging to the Herpesviridae family. The first form, considerably diffused, is responsible for the
appearance of characteristic febrile vesicles which normally affect the facial skin (lips, nostrils), it
is also called herpes simplex labial. Initially, the cold sores manifest themselves with a slight
tingling and a sense of heat on a reddened point of the lip (Crimi, et al, 2019).

Chicken Pox ICD 10 B01

Chickenpox (varicella) is a very common childhood infection caused by the Varicella-zoster

virus. It is most common in children and is usually mild. When adults get it, however, they can
get very sick. Chickenpox is dangerous for people with immune system problems, such as
leukemia, or for people who are taking drugs that weaken the immune system, such as steroids.

Dermatitis ICD 10 L 30.9

The clinical manifestations of Atopic Dermatitis vary with age. In infants, the scalp, face, neck,
trunk and extensor (outer) surfaces of the extremities are generally affected, while the diaper
area is usually spared. Children typically have involvement of the flexural surfaces of the
extremities (I,e., fold/bend at the elbow and back of the knee) , neck, wrists and ankles.
Regardless of age, the itching associated with AD generally continues throughout the day and
worsens at night, leading to sleep loss and substantial impairments in quality of life ( Kapur,
Watson & Carr, 2018).

Plan
Plan Treatment Plan (Written as directive and numbered) include:

There is no specific treatment for hand, foot, and mouth disease. The Doctor prescribed
Tylenol to relieve the fever and pain caused by mouth sores. He also educated the mother
to keep her daughter hydrated. He further educated the parent of what are the things to
look for and be educated about.

1. Nail beds might come off after a couple of weeks.

2. Patient should not go to school until after 1 week because they are contagious.
3. Patient should be educated to wash her hands.
4. The parent should also remind her daughter to avoid touching her eyes, nose and
mouth.

The parents is advised to come back to the clinic after a week.

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 References:

Hand, Foot, and Mouth Disease (HFMD). (2021). Centers for Disease Control and Prevention.
Retrieved from https://www.cdc.gov/hand-foot-mouth/index.html

Crimi, S., Fiorillo, L., Bianchi, A., D'Amico, C., Amoroso, G., Gorassini, F., Mastroieni, R.,
Marino, S., Scoglio, C., Catalano, F., Campagna, P., Bocchieri, S., De Stefano, R.,
Fiorillo,
M. T., & Cicciù, M. (2019). Herpes Virus, Oral Clinical Signs and QoL: Systematic
Review of Recent Data. Viruses, 11(5), 463. https://doi.org/10.3390/v11050463

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Kapur, S., Watson, W., & Carr, S. (2018). Atopic dermatitis. Allergy, asthma, and clinical
immunology : official journal of the Canadian Society of Allergy and Clinical
Immunology, 14(Suppl 2), 52. https://doi.org/10.1186/s13223-018-0281-6