CHIEF COMPLAINT: Prematurity and respiratory failure.

MATERNAL HISTORY: Mom is a (XX)-year-old gravida 3, para 2-0-0-2 Asian woman who did receive prenatal care. Her labs include A positive blood type, antibody negative, hep B surface antigen negative, rubella immune, VDRL nonreactive, GBS unknown and herpes denies.

She received steroids x2 doses. She received antibiotics less than 4 hours prior to delivery. The pregnancy was complicated by advanced maternal age, morbid obesity, prolonged premature rupture of membranes for about three weeks and placental abruption. She was admitted for spontaneous rupture of membranes and has been in the PSCU. Her EDC is MM/DD/YYYY. Decision was made to C-section today for abruption and breech presentation.

DELIVERY SUMMARY: The baby is a 1264 gram product of a 28 plus 1 week gestation pregnancy born MM/DD/YYYY at XXXX a.m. by C-section. Anesthesia was spinal. Spontaneous rupture of membranes occurred on MM/DD/YYYY, which was about three weeks ago. Fluid was clear/bloody. Apgars were 5, 4, 6 and 7 at one, five, ten and fifteen minutes respectively.

The infant came out with a small cry, was active, but had very poor air entry, tight breath sounds and minimal respiratory effort. Saturations were in the 40s. CPAP was begun. Shortly thereafter, positive pressure ventilation was begun secondary to minimal respiratory effort and low saturations. FiO2 was increased gradually to 100%.

At 4 minutes of life, he was intubated and bag mask ventilation was continued. Sats were slowly increasing. He was given surfactant at about 14 minutes of life and his saturations then increased into the 90s. FiO2 was slowly weaned down to 60%, and he was transferred to the NICU on the Neopuff. See the delivery summary for more detailed account of baby’s resuscitation.

PHYSICAL EXAMINATION:
VITAL SIGNS: Heart rate is 178, respiratory rate is undeterminable as he is on high-frequency ventilation, temperature is 37.4 degrees Celsius, blood pressure 60/32 with a mean of 43, saturations 94% on 65% oxygen. Weight is 1264 grams, length 37.4 cm, FOC 26 cm, all of which are around the 50th percentile.
HEENT: Anterior fontanelle soft and flat. Sutures are approximating. Pupils are equal and reactive to light with red reflexes bilaterally. Mucous membranes of the mouth and nose are pink and moist. He is intubated.
NECK: Soft with good range of motion. Clavicles are intact.
CHEST: He has very tight breath sounds. Fair air entry. Mild subcostal and intercostal retractions and now with good bounce on high-frequency ventilation.
HEART: He has a regular rate and rhythm. No murmur is heard. Cap refill time of 3 seconds and good pulses in all four extremities.
ABDOMEN: Soft and nondistended with hypoactive bowel sounds.
GENITOURINARY: He has a 3-vessel cord.
GENITALIA: Normal male genitalia. Testes are in the canal bilaterally. Anus is patent.
EXTREMITIES: Grossly normal. There is breech positioning of the legs.
BACK: Straight with no tufts or dimples.
SKIN: Pink and intact.

LABORATORY DATA: Glucose of 65. ABG, the pH is 7.26, pCO2 of 52, pO2 of 60, HCO3 of 22 and base deficit of -6.

IMPRESSION: This is a (XX) plus (X) week gestation male with respiratory distress syndrome, rule out sepsis and hypoplastic lungs.

PLAN:
1.  N.p.o. We will place the UAC and UVC. We will begin total parenteral nutrition and follow labs in the morning.
2.  We will continue high-frequency oscillatory ventilation. Obtain ABGs every one to two hours. Obtain a chest x-ray. Once the lines are placed, he may need a second dose of surfactant.
3.  Obtain a blood culture and CBC now. Begin ampicillin and cefotaxime. Follow CBC, CRP in the morning and send a tracheal aspirate.
4.  Head ultrasound in the morning.
5.  Nutrition consult.
6.  We will update the family. The father of the baby was updated. We will continue to update him and the mother while the infant is here in the NICU.

DATE OF DISCHARGE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with history of mild intermittent asthma, who was in her usual state of health until admission. The child is managed at home with albuterol p.r.n. Mother denied any daily symptoms of asthma. The child did have some complaints of coughing at night. The child was fine until the evening prior to admission when she developed cough, wheezing, and some chest tightness. Despite multiple puffs of albuterol at home, the child was taken to the emergency room due to her increased work of breathing and increased difficulty in breathing.

Multiple treatments were given in the emergency room without much relief, and the child was admitted to pediatric for further treatment and nebulizer therapy. O2 saturations in the emergency room were 93% on room air.

PHYSICAL EXAMINATION: GENERAL: On admission, the child was alert, in mild acute respiratory distress. LUNGS: The child had diffuse mild wheezing bilaterally. There was decreased air entry. There were no rales noted. The remainder of the physical examination was unremarkable.

ASSESSMENT:  A (XX)-year-old female with acute exacerbation of asthma.

HOSPITAL COURSE:  Albuterol and Atrovent nebulizers were given as well as IV Solu-Medrol, Pepcid, and O2 via nasal cannula to maintain stable O2 saturations. By the next day, the child had shown some improvement but still had some decreased breath sounds over the right lung field but was in no respiratory distress at this point. Nebulizers will be continued as well as IV Solu-Medrol, and the child showed clinical improvement.

On the day of discharge, the child was doing much better, was on room air, still had some decreased air entry of the right lung field but improved from the previous examinations. Due to the child’s clinical improvement, the decision was made to discharge the child home on p.o. Orapred and continue nebulizer therapy at home. The child is to follow up with PMD in 24-48 hours.

FINAL DIAGNOSIS:  Asthma, acute exacerbation.

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.

DATE OF DISCHARGE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-and-(XX)-month-old African-American female child who was admitted through the emergency room on the day of admission with a history of coughing and being sick for two to three days. Mother was treating her at home with the nebulizer machine, giving her treatments every four to six hours and noticed that the child was breathing hard and breathing heavy, so she decided to bring her to the emergency room. There is no history of fever, vomiting, diarrhea, and no other health condition, except for the breathing problem.

PAST MEDICAL HISTORY: Significant for this being a term child. Had no problems initially and no problems needing oxygen, but when she was 2 or 3 months old, we think she had episodes of bronchiolitis, and since then, has developed wheezing and asthma for which she received nebulizer treatment. She was hospitalized once for a few days.

SOCIAL HISTORY: The child stays with mother and father and siblings, and there is a family history of asthma. The parents smoke and have been counseled about the importance of smoke-free environment for the child since she definitely gets into trouble with cigarette smoke. The child is up-to-date on immunizations, and growth and development have been appropriate. She is a climber. She climbs on everything. She copies whatever you say, and she is a busy child with some good temper tantrums.

HOSPITAL COURSE: In the emergency room, initially, she had a low-grade fever and her respirations were 34 to 38. Her pulse oximetry in the emergency room was in the 80s, so at this point, she was placed on O2 by nasal cannula, which the child was having problems keeping the nasal cannula in, and she continued to receive some oxygen supplement. The nasal cannula was discontinued the next day, and instead, we put her in a mist tent, which was more tolerable to her. Her pulse oximetry was better and it remained in the high 90s; although, it was difficult to keep the child in the mist tent for long. WBC count was 11,600 initially with a normal differential. Her electrolytes were also within normal limits. Her RSV, which was sent from the emergency room, is still pending. Her chest x-ray was read as having some lingular pneumonia. She was placed on oral Zithromax and Orapred. She is receiving nebulizer treatments, which consisted of Xopenex, initially more frequently and subsequently every four hours and p.r.n. Since yesterday, the child has been afebrile, eating good, and busy. We have discontinued her mist tent, and she seemed to be doing good with pulse oximetry, and her respirations are in 20s, 24 today. It was decided to send her home.

PHYSICAL EXAMINATION: General: The patient is sitting on the bed playing. There is no nasal flaring or retractions. She has got a good color. Vital Signs: Her respiratory rate is 22 to 24. HEENT: Her pupils are equal, round, and reacting to light. Her oral mucosa is pink and moist. Tympanic membranes are healthy. Lungs: Good air entry bilaterally with end-expiratory wheezes still. Heart: Regular sinus rhythm. No tachycardia. Abdomen: Soft. No tenderness. No masses. Bowel sounds are present. Extremities: Full range of movement. Genitalia: External female. Skin: Good turgor, and there are no rashes.

ASSESSMENT AND PLAN: The patient is an approximately (XX)-year-old little girl with a known history of asthma who had a flare-up, which is probably due to the lingular pneumonia, which seemed to be resolving, so I am sending her home today. She does not need any Zithromax anymore, she has received it for four days, but she will be taking some Orapred, tapering doses, for the next two days and then also receiving nebulizer treatments every four hours. Mother has been advised to minimize exposure to cigarette smoke again and she understands. She will be seen in our office tomorrow for a followup and also for a flu shot.