Elizabeth Katz

SOAP note 3

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7-month-old female, no pmhx presents to ED with mother and grandmother from the QHC pediatric clinic with c/o respiratory distress. The patient’s mother states that she had a fever last night at 7:47 p.m. (Tmax 103°F axillary) and Tylenol was given with some reported improvement. She reports that at 1:00 a.m. she began to notice that the patient was “breathing heavy” and that she seemed to be less active than usual at 6:00 a.m. this morning prompting her to call and get an appointment with her PCP. Mother states that she has had a mild cough and congestion for the past 2 days but denies difficult or labored breathing until this morning, N/V/D, difficulty eating or drinking, sick contacts, or recent travel. She reports that her daughter has been having wet diapers and making stool and denies any blood in the stool. She is not in daycare and is reported as being up-to-date with all of her vaccines.

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1. VS: BP 107/68; pulse 165 regular; O₂sat 81% room air; respirations 70/min; temp 99.1°F rectal; weight 18.1 lbs
2. Patient is mildly lethargic but roused by stimulus, in moderate respiratory distress
3. HEENT

• Head: normocephalic atraumatic, anterior fontanel present
• Eyes: sclera and conjunctiva clear
• Ears: TMs intact and pearly grey b/l
• Nose: septum mildline with clear rhinorrhea noted
• Mouth: oral mucosa pink and moist, uvula midline, no tonsillar swelling or exudates noted

4. Neck: supple, no masses noted
5. Nodes: no lymphadenopathy
6. Skin: good turgor, capillary refill < 2 sec throughout, 4cm Mongolian spot noted on left sacral, gluteal region
7. Chest: diffuse b/l wheezing heard throughout with prolonged expiratory phase, +subcostal and sternal notch retractions with accessory muscle use
8. Heart: tachycardia, no heaves, gallops, murmurs
9. Abdomen: soft, flat, bowel sounds present, non-tender to palpation, liver edge, spleen, kidneys not felt

Labs:

1. CBC – pending at the time of transfer
2. Rapid RSV immunoassay – POSITIVE
3. Influenza swab – pending at the time of transfer

Imaging:

1. CXR: perihilar congestion noted b/l, no opacities or consolidations noted

Assessment:7-month-old female, no pmhx presents to ED with mother and grandmother from the QHC pediatric clinic in moderate respiratory distress. The patient is tachypnic to 70 with an O₂saturation of 81% on room air, moderate subcostal and sternal notch retractions and accessory muscle use is noted. She is currently afebrile and responds to sensory stimulus. Mother states she has been feeding as per usual and denies sick contacts or recent travel.

Plan

• Place on continuous monitoring
• Administer nebulized saline and oxygen via mask at 2L/min
• Obtain CBC, RSV swab and flu swab
• Obtain CXR
• Call LIJ to begin transfer process

DDx(initial):pneumonia, bronchiolitis, foreign body aspiration, croup, flu

DDx(refined):RSV bronchiolitis, croup

Patient education:

• Clear nasal secretions with saline and suction regularly
• Steam up bathroom and sit in there WITH the baby for 15-20 minutes 3x a day – DO NOT LEAVE BABY IN THE BATHROOM ALONE
• Place a cool mist humidifier in the baby’s room
• Wash hands often
• Keep the baby hydrated
• Administer Tylenol or Motrin as needed for fever control
• Return to the ED if the baby seems to be struggling to breathe, if she becomes less active, if she has persistent fever > 4 days, or if the fever spikes unusually high