Soap note topic: Pediatric Adolescent female with a chief complaint of burning with urination.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S = Subjective data: Patient’s Chief Complaint (CC).
O = Objective data: Including client behavior, physical assessment, vital signs, and meds.
A = Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P = Plan: Treatment, diagnostic testing, and follow up
Submission Instructions:
Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
Soap note must include prescription at the end for the pediatric patient.
Soap note must be very detailed for the pediatric patient.
Use Soap note template attached below
S: “I’ve been feeling like I need to pee all the time lately, and it really burns when I go. It’s been going on for a few days now. I’m not feeling sick otherwise.”
O: Vitals: T 37.2°C, P 90, RR 18, BP 110/70. General appearance well but in mild discomfort. Abdomen soft, non-tender, no rebound or guarding. Urine dipstick positive for leukocyte esterase and nitrites. Microscopic urinalysis shows >10 WBCs/hpf and bacteriuria.
A: 1. Uncomplicated cystitis
2. Escherichia coli UTI
P: 1. Obtain urine culture and sensitivity
2. Trimethoprim-sulfamethoxazole 160/800 mg PO BID for 7 days
3. Hydrate well with water
4. Follow up in 2 weeks if no improvement or earlier if symptoms worsen
5. Provide patient and family education on prevention of recurrent UTIs
Prescription:
Amoxicillin 250mg capsules
Take 1 capsule by mouth twice daily for 7 days with food
Refill x 0
