Pediatric SOAP Note example

Pediatric SOAP Note Example

Here’s a pediatric soap note example that shows all the parts of the SOAP Notes: Subjective, Objective, Diagnosis, and Plan.

S: Subjective

Chief Complaint (CC):
Mother states: “Emily has had a fever and cough for the past three days. She’s been more tired than usual and not eating well.”

History of Present Illness (HPI):

• Onset: 3 days ago
• Duration: Persistent, worsening at night
• Character: Dry, non-productive cough, mild congestion
• Severity: Mild to moderate; fever fluctuating
• Associated Symptoms:
  • Fever (reported up to 101.3°F)
  • Reduced appetite
  • Fatigue
  • No vomiting, diarrhea, or rash
• Aggravating/Relieving Factors:
  • Worse at night
  • Slight improvement with acetaminophen (Tylenol)
• Recent Sick Contacts: Older sibling had a cold last week
• Immunization Status: Up to date

Past Medical History (PMH):

• Full-term birth, no complications
• No significant medical conditions
• No hospitalizations or surgeries

Medications:

• Acetaminophen (as needed for fever)

Allergies:

• No known drug allergies

Family History:

• Mother: Seasonal allergies
• Father: No chronic illnesses
• Older brother: Asthma

Social History:

• Attends preschool
• Lives with parents and older brother
• No pets
• No exposure to smoke

O: Objective

Vital Signs:

• Temperature: 100.9°F (tympanic)
• Heart Rate: 105 bpm
• Respiratory Rate: 24 bpm
• Blood Pressure: 95/58 mmHg
• Oxygen Saturation: 98% on room air
• Weight: 15.5 kg (50th percentile)
• Height: 98 cm (55th percentile)

Physical Exam:

• General: Alert, slightly fatigued but interactive
• HEENT:
  • No conjunctival injection
  • Nasal congestion, clear rhinorrhea
  • Oropharynx mildly erythematous, no exudates
  • Tympanic membranes intact, no bulging or erythema
• Neck: No lymphadenopathy
• Respiratory:
  • Mild nasal flaring
  • No retractions
  • Clear breath sounds bilaterally, mild scattered wheezes
• Cardiovascular: Regular rate and rhythm, no murmurs
• Abdomen: Soft, non-tender, no hepatosplenomegaly
• Skin: No rash, well-hydrated
• Neurological: No focal deficits, appropriate behavior for age

A: Assessment (Diagnosis & Differential Diagnoses)

Primary Diagnosis:

• Viral Upper Respiratory Infection (URI)
  • Most likely due to a common viral pathogen such as rhinovirus, adenovirus, or respiratory syncytial virus (RSV).
  • Symptoms are consistent with a mild viral illness, including fever, cough, nasal congestion, and fatigue.
  • No signs of bacterial infection or serious complications such as pneumonia.

Differential Diagnoses:

1. Viral Bronchiolitis
   • More common in infants and young children under 2 years.
   • Caused primarily by RSV but can also be due to other respiratory viruses.
   • Symptoms include wheezing, cough, nasal congestion, and respiratory distress.
   • Less likely in Emily’s case due to her mild symptoms and lack of significant respiratory distress.
2. Bacterial Pneumonia
   • Less likely due to the absence of focal lung findings (such as crackles, rales, or decreased breath sounds).
   • Pneumonia is usually associated with high fever, productive cough, and signs of respiratory distress, which Emily does not exhibit.
   • Would consider if fever persists beyond 4-5 days, worsens, or if breathing becomes labored.
3. Strep Pharyngitis (Group A Streptococcus)
   • Unlikely due to the lack of exudates, significant throat pain, or history of strep exposure.
   • Strep throat is more common in older children and often presents with fever, sore throat, and sometimes a rash (scarlet fever).
4. Allergic Rhinitis
   • Possible but unlikely given the presence of fever and systemic symptoms.
   • Would consider if symptoms persist beyond 2 weeks without fever and include sneezing, clear nasal discharge, and itching.

P: Plan (Management & Treatment)

1. Treatment Plan (Symptomatic and Supportive Care)

Since this is most likely a viral infection, treatment is supportive rather than antibiotic-based. Viruses do not respond to antibiotics, and unnecessary antibiotic use can contribute to resistance and side effects. Instead, symptom relief and close monitoring are key.

• Fever Management:
  • Continue acetaminophen (Tylenol) as needed for fever and discomfort.
  • Dosage: 10-15 mg/kg every 4-6 hours as needed (do not exceed 5 doses in 24 hours).
  • Avoid ibuprofen if there are signs of dehydration.
• Cough & Congestion Relief:
  • Increase hydration: Warm fluids (soups, warm water, herbal teas) can help soothe the throat.
  • Honey (for children over 1 year): ½ to 1 teaspoon before bedtime may help reduce cough frequency.
  • Saline nasal drops & suctioning: Helps clear nasal congestion, especially before feeding and sleeping.
  • Cool mist humidifier: Keeps airways moist and reduces nighttime coughing.
  • Elevate head during sleep: A slight incline (by placing an extra pillow under the mattress) can help with drainage.
• Nutrition & Hydration:
  • Offer small, frequent meals and fluids to prevent dehydration.
  • Watch for signs of dehydration, such as dry mouth, fewer wet diapers, crying without tears, or lethargy.
• Rest & Recovery:
  • Encourage plenty of rest.
  • Reduce exposure to irritants (smoke, strong scents) that could worsen cough.
• Avoid Over-the-Counter Medications:
  • Cough and cold medications are not recommended for young children due to potential side effects and lack of proven benefits.

2. Diagnostic Plan

• No immediate need for laboratory tests or imaging at this stage.
• Consider additional testing if symptoms worsen or persist beyond expectations:
  • Rapid strep test if sore throat becomes severe.
  • Chest X-ray if persistent fever, difficulty breathing, or worsening cough suggests pneumonia.
  • Viral panel if severe illness is suspected, though this is usually unnecessary in mild cases.

3. Follow-Up Plan & Red Flags

• Routine Follow-Up: If symptoms do not improve in 3-5 days, return for reevaluation.
• Seek Immediate Medical Attention If:
  • Fever exceeds 102°F for more than 3 days.
  • Child develops difficulty breathing (fast breathing, chest retractions, or flaring nostrils).
  • Persistent vomiting or refusal to drink, leading to signs of dehydration.
  • Symptoms suddenly worsen instead of improving.
  • Child becomes unusually drowsy, unresponsive, or lethargic.

4. Parental Education & Counseling

• Viral illnesses are self-limiting and usually resolve in 7-10 days.
• Antibiotics are not needed for viral infections and do not help with symptom relief.
• Hand hygiene is essential to prevent the spread of infections within the household.
• Encourage cough etiquette (cover mouth with elbow, wash hands frequently).
• Safe medication use: Avoid aspirin (risk of Reye’s syndrome in children).
• If child returns to daycare/school, ensure she is fever-free for at least 24 hours without fever-reducing medication.

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