South University Family Nurse Practitioner

Pediatric EPISODIC SOAP Note Template

Student’s Name: Date:

Hephzibah Tranquilan 2/10/2021

Patient / Client initials: Age:

A. B 7-year-old

Gender: Ethnicity:
Male
Caucasian
Historian:
Mother

SUBJECTIVE DATA

Chief Complaint 7-year-old Caucasian boy accompanied by his mother. His mother said, “my son is
(CC) complaining that he is seeing lights and spacing out”. The mother said that her son
keeps staring into space and she is trying to snap him out of it and nothing works.

History of
Present Illness The boy is presented to the clinic with his mother. He has been having episodes
(HPI) where he stares into space for a moment, and it has been going on for 6 months
now. The mother said that the episodes usually last 10-30 seconds. The character of
the spacing has no specific, the boy as per mother is just unresponsive. The mother
said that there is no relieving factor, and the child eventually snaps out of it. It does
not have a pattern and it randomly appears anytime of the day. The episodes do not
vary in severity.

The child has been diagnosed with mild ADHD and there has been question whether
Past Medical the patient is autistic. He is currently receiving behavioral therapy for ADHD and his
History (PMH) mother states that it seems to be working well.

The mother reported that so far as she knows there is no medical issues with the
Family History boy’s father and she also relayed that she is healthy and not taking any medication.

Social History The parents are divorced and the patient lives with his mother. They do not have pets in the
house. He is the only child, and he lives with the mother and the dog.

Multi vitamins daily

Medication
Reconciliation /
Review

Allergies

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 No known drug allergies
Immunizations
Up to date.

The patient is up to date with her immunizations and the mother said that she takes
Health him to playdates with his cousins.
Promotion/
Health
Maintenance

Constitutional Symptoms:

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

The patient’s mother denies any vision problems, tics, strabismus nor nystagmus experienced
by the child. No drainage from eyes. Denies any pain or itching to bilateral eyes. Patient do not
use eyeglasses.

Head:
The patient denies experiencing any headaches, he denies any discomfort nor itching on his
scalp.

Ears, Nose, Mouth, Throat:

The patient’s mother denies any ringing on his ears, nausea, any nasal discharge.

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

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

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

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

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

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

Hematologic/Integumentary:
The patient denies any bruises on any part of his body.

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

Objective

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Vital Signs Vital Signs:

Temperature: 97.3 (Temporal) Blood Pressure: 98/63

O2 Saturation: 100% Weight: 35.2 lbs
Respiratory Rate: 23m Height: 124.46 cm
Heart Rate: 82 bpm

Systems/Body Areas of Physical Examination

General appearance:
Maternal/Child both appear well kept and are in clean clothing, interaction is normal, mother is
very attentive to child needs.

Physical Skin:
Examination Texture and appearance are within normal range, no pigmentation noted. Good skin turgor
especially of the calf muscles and skin over the abdomen. General skin overview reveals no
(PE) significant rash or other lesion.

HEENT:

Head: Normocephalic, no lesions.

Eyes: PERRL, 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. Oral mucosa wet, no adenopathy 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, no rash noted.

Musculoskeletal: No pain/discomfort noted with passive ROM of joints.

Male Genitalia:
The baby is uncircumcised, testes descended bilaterally, no hernia noted. No sores or lesions
noted. A mild erythematous skin noted around the genitalia.

Spine and Back:

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

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 Neurologic:
Alert and appropriate for age. No signs of focal motor or sensory deficit. Appropriate exam for
age.

Assessment
Diagnosis Diagnosis (Dx)

True Absence seizure (petit mal) ICD 10 G40. A

An absence seizure causes you to blank out or stare into space for a few seconds. They can
also be called petit mal seizures. Absence seizures are most common in children and typically
do not cause any long -term problems. These types of seizures are often set off by a period of
hyperventilation. Absence seizures usually occurs in children between ages 4 to 14. A child may
have 10, 50, or even 100 absence seizures in a given day and they may go unnoticed. Most
children who have typical absence seizures are otherwise normal. However, absence seizures
can get in the way of learning and affect concentration at school. This is why prompt treatment is
treatment. Absence seizures are a type of epilepsy, a condition that causes seizures. Seizures
are caused by abnormal brain activity. These mixed messages confuse your brain and cause a
seizure (Hopkins’s medicine, 2021).

Differential Diagnosis (DDX)

Transient Alteration of Awareness ICD 10 R 40.4

Transient alteration of consciousness is a major clinical challenge of neurology. Evaluating

transient impairment of consciousness is critical to diagnose epileptic seizures, syncope,
parasomnias, organic encephalopathies, and psychogenic nonepileptic seizures (PNEs).
Syncope is a common cause of sudden alteration of consciousness, typically preceded by
lightheadedness and rarely lasting longer than a minute. Early referral of recurrent syncope for
cardiologic consultation is important due to a number of etiologies that constitute life-threatening
cardiac conditions (Henry & Ezzeddine, 2012).

Seizure (CMT) ICD 10 G40.909

Seizures are symptoms of a brain problem. They happen because of sudden, abnormal
electrical activity in the brain. When people think of seizures, they often think of convulsions in
which a person’s body shakes rapidly and uncontrollably. Not all seizures cause convulsions.
There are many type of seizures and some have mild seizures, also called partial seizures,
happen in just one part of the brain. Generalized seizures are a result of abnormal activity on
both sides of the brain (Medline, 2021).

Autism ICD 10 F84.0

Autism is not a single disorder, but a spectrum of closely related disorders with a shared core of
symptoms. Every individual on the autism spectrum has problems to some degree with social
interaction, empathy, communication, and flexible behavior. But the level of disability and the
combination of symptoms varies tremendously from person to person. In fact, two kids with the
same diagnosis may look very different when it comes to their behaviors and abilities. Many
children with Autism Spectrum Disorder struggle with speech and language comprehension.
Symptoms may include: delay in learning how to speak (after the age of two) or doesn’t talk at all
or difficulty communicating needs or desires (help guide, 2021) .

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

Educated parents on keeping a journal when episode occur, what is going on around him
and how long they last.

True absence seizures (petit mal) are seizures that cannot be predictably interrupted by
calling the child’s name or by tactile stimulation. It appears as if the person is having
staring spells or behavioral laicity or basically “spacing out”. This condition is very common
in children who have been previously diagnosed with attention deficit hyperactivity
disorder (ADHD). When an absence seizure occurs it usually occurs during conversation
or physical activity and looks as if they are daydreaming. These seizures usually happen
multiple times a day(Wilfong, Nordli Jr, & Eichler, 2018).

The child will be referred to a Neurologist. If child has seizure prior to visit with neurology
please go to the nearest emergency room.

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 References:

Absence Seizures. (2021). What are absence seizures? John Hopkins Medicine. Health.
Condition
and diseases. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-
diseases/epilepsy/absence-seizures

Autism Spectrum Disorders. (2021). Help Guide Organization. Autism. Retrieved from
https://www.helpguide.org/articles/autism-learning-disabilities/autism-spectrum-
disorders.htm

Henry, T. R., & Ezzeddine, M. A. (2012). Approach to the patient with transient alteration of
consciousness. Neurology. Clinical practice, 2(3), 179–186.
https://doi.org/10.1212/CPJ.0b013e31826af1be

Seizures. (2021). Medline Plus. Truested Health Information for you. U.S. National Library of
Medicine. Retrieved from https://medlineplus.gov/seizures.html

Wilfong, MD., Nordli, A., Eichler, M., (2018, September 23). Seizures and epilepsy in children:
Classification, etiology, and clinical features.
https://www.uptodate.com/contents/seizures-and-epilepsy-in-children-classification-etiology-
and-clinical-features