PEDIATRIC SOAP NOTE EXAMPLE #1
CHIEF COMPLAINT: Sore throat.
SUBJECTIVE: The patient has had a two-day history of sore throat that is associated with some inspiratory difficulty, especially at night, and chest pain with sneezing and coughing. The patient’s grandmother said that he did have some barking with his cough overnight. This was also associated with congestion and coryza. There is no headache, earache, wheezing, stomach ache, nausea, vomiting, or diarrhea. The patient says he is experiencing the inspiratory difficulty now.
OBJECTIVE: Temperature is 97.8, blood pressure is 96/62, weight is 70 pounds. In general, the patient looks well and in no distress. We do not detect any inspiratory stridor nor see that he has any difficulty breathing in. The tympanic membranes were normal bilaterally. He had a clear nasal discharge with red mucosa. Oropharynx reveals no redness, exudate, swelling, or ulcerations. There is no neck adenopathy. The lungs are clear to auscultation with good breath sounds. There were no rales, rhonchi, or wheezes. Cardiovascular examination revealed a regular rate and rhythm with no murmur. Abdominal examination was normal.
ASSESSMENT:
1. Croup with slight overnight stridor.
2. Possible associated bronchitis, that would also be of a viral nature and therefore not responsive to antibiotics.
PLAN:
1. Cold air at night when he sleeps and cold mist humidifier at night as well.
2. For any inspiratory difficulty, he should go in the bathroom with the shower running and producing steam.
3. Call for any worsening of symptoms.
4. Follow up for any other changes.
PEDIATRIC SOAP NOTE EXAMPLE #2
REASON FOR VISIT: The patient is here today because of small pus on the side of his right fingernail.
SUBJECTIVE: The patient is a nail biter. He has anxiety. He noted pain and now a little pus on the side of his fingernail. He has the same area of infection in between the thumb and the index finger. He did not have any fever.
OBJECTIVE: The patient is ambulatory. He appears well. He is afebrile with a temperature of 97.6. Detailed physical examination was not done today. On examination of his right hand, he has small pus with an area of redness on the medial aspect of the third middle nail bed. He has also small, but open pus-containing wound in the area between the thumb and index finger.
PROCEDURE: The right medial finger was cleaned with isopropyl alcohol. A small incision was made. There was a small amount of pus that came out from possibly the side of the abscess. This was swabbed and sent out for culture.
ASSESSMENT: Microabscess, side of the medial finger, cannot rule out the possibility of methicillin-resistant Staphylococcus aureus. Also, wound between the thumb and index finger, possible etiologic agent of methicillin-resistant Staphylococcus aureus also.
PLAN: The patient will soak his right hand in warm water for 15 minutes 3 times daily. He will be given Bactrim suspension. He will take 2 teaspoons 2 times daily for 10 days. Followup will be as necessary.
PEDIATRIC SOAP NOTE EXAMPLE #3
CHIEF COMPLAINT: Fever.
SUBJECTIVE: This morning, the patient was complaining of a stomach ache and had an associated fever. She complained of a sore throat once today and has a brother who was diagnosed and treated for streptococcus a week ago. She is not currently complaining of any earache, congestion, coryza, cough, chest pain, dyspnea, wheezing, nausea, vomiting, or diarrhea.
OBJECTIVE: Temperature is 101.2 orally, blood pressure 92/60. Weight is 50 pounds. In general, the patient looks well and in no acute distress. Her cheeks were rather red. Tympanic membranes were normal bilaterally. She had some nasal congestion. Oropharynx revealed no redness, exudate, swelling, or tonsillar enlargement. She had no neck adenopathy. Lungs were clear to auscultation with good breath sounds. There were no rales, rhonchi, or wheezes. Cardiovascular examination revealed regular rate and rhythm. No murmur. Abdominal examination was normal.
LABORATORY DATA: Rapid strep was negative.
ASSESSMENT:
1. Viral pharyngitis.
2. No evidence of focal infection.
PLAN:
1. Check the throat culture to make sure it is not strep.
2. Symptomatic treatment for pain and fever.
3. Follow up for any other significant changes.
PEDIATRIC SOAP NOTE EXAMPLE #4
SUBJECTIVE: The patient is now (XX) days old, and she is here for her routine two-week well-baby newborn visit. The patient has done well since we saw her a week ago at this office. She is feeding well. She takes Similac Advance about 2 to 3 ounces every time, sometimes as much as 3-1/2 ounces. She occasionally does spit up. Last night, she was a little fussy from 8:00 at night to 11:00, almost midnight. Her bowel movements are plenty. She has many per day, and she is wetting her diapers well. The patient is well taken care of by mom. Mom is very mature and confident about the baby’s care.
OBJECTIVE: The patient is a beautiful baby. Length is 20-1/2 inches, 85th percentile. Weight is 7 pounds and 11 ounces and that is 62nd percentile. Head circumference is 40 inches, 69th percentile. HEENT: Head is normocephalic. Anterior fontanelle is open and flat. Both eyes are clear. Red-orange reflexes are positive in both eyes. Nose: Clear. Mouth is clear. There is no neck mass. Chest and Lungs: Clear. Heart: Normal. No murmurs, regular rhythm. Abdomen: Not distended, soft, no mass, no tenderness. No hepatosplenomegaly. External Genitalia: Normal female. Extremities: Hips are stable even on manipulation. The femoral pulses are easily palpable. There is no MTA deformity. Spine: No sacral dimple, straight. Skin: Clear. Neurologic Examination: Normal.
ASSESSMENT: The patient is a well (XX)-day-old infant.
PLAN: Routine newborn care was reviewed with mom. Mom will offer feedings every 2 to 3 hours during the day and at longer intervals at night. We advised mom to burp the baby well during the feedings. We would like to see her again when she turns a month old, and at that time, she will get her second hepatitis B vaccine.
