South University Family Nurse Practitioner

Pediatric EPISODIC SOAP Note Template

Student’s Name: Date:

Hephzibah Tranquilan 1/12/2021

Patient / Client initials: Age:

W. M. 2 months

Gender: Ethnicity:
Male
Cuban American
Historian:
Mother and father who are immigrants
from Cuba. They are good and reliable historian.

SUBJECTIVE DATA

Chief Complaint The mother said that “we are here for a 2 month old well-baby checkup”.
(CC)

History of
Present Illness The baby is presented to the clinic for a well-baby checkup. He has been a patient of
(HPI) the clinic since he was 4 days old. The mother reported that he has not have any
symptoms of poor appetite and is eating alright. There was no discomfort noted,
irritability or any effect on the baby’s daily activities. The mother reported that the
neurologist deemed her son’s case will be resolve on its own. She also said that she
changed direction of the baby is lying on the crib on a regular basis to ensure that he
is not always resting on the same part of the head.

.
Past Medical
History (PMH) The baby was naturally delivered by his mother on November 12, 2020 in Winnie
Palmer Hospital, the APGAR score was 8, the birth went uneventful. The mother
denies any history of taking any medications nor alcohol during the pregnancy.
Family History
The mother is 28 years old and denies any health issues. The father is 35 years old,
denies any health issues. Maternal and paternal grandparents are alive and living in
Cuba. He has no siblings.

Social History
The baby is living with his parents. They do not have pets. The baby socializes with
his parents and his parent’s friends when they visit their house. According to parents
the baby mumbles, lift up his head when he is put on his tummy and also follows
“mommy” with his eyes when she is interacting with him.

Medication The parents said that the baby does not have any medication that he is currently
Reconciliation / taking except for the Desitin they are currently using for the baby’s diaper rash.
Review

Allergies
No known drug allergies
Immunizations
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 Hepatitis B – December 12, 2020.

The baby is breast feed by the mother. He had his one month well baby check-up last
Health December 12, 2020 and did his Hepatitis B vaccination number 1.
Promotion/
Health
Maintenance

Constitutional Symptoms:

Review of The parents deny that the baby has any fever, change in activity level, or night sweats.
Systems (ROS)
Eyes:

The parents said that the baby follows and stare at the parent if they are communicating with
him.
The parents deny any vision problems, tics, strabismus nor nystagmus experienced by the baby.

Head:
The parents reported that the right side of baby’s head is flat and that they are concerned. The
parents reported that the baby favored the right side of his head to sleep.

Ears, Nose, Mouth, Throat:

The parents said that the baby responds to sudden noise by startling response and blinking. The
parents also said that the baby changes his body movement in responds to the sound elicited by
the parent. The mother also said that the baby turns his eyes and head to the sound. The
parents deny any frequent colds, sneezing, stuffy nose, for the baby

Teeth:
The parents deny that the baby is teething. They reported he has not had any teeth growth yet.

Cardio/Respiratory:
The parents said that the baby is not experiencing any dyspnea, cough, wheezing or cyanosis
episodes.

Genitourinary:
The parents deny any symptoms of abnormalities in his penis or testes.

Gastrointestinal:
The parents reported that the baby has not had any diarrhea, constipation or experience any
abdominal pain or discomfort.

Neuromuscular:
The parents said that the baby does not have any convulsions, spasms.

Endocrine:
The parents said that the baby does not have any disturbances in growth, he has no problem
feeding.

Hematologic:
The parents said that the baby does no bruise easy. The parents admitted that they were
concerned when the baby in his first 3 weeks color was a “little bit” yellow, but now he does not
have that color.

Rheumatologic:
The parents deny any problems with the baby’s joint. The reported that the baby does not have
any swollen, pain nor stiffness noted around his body parts.

Skin:

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 The parents reported that the baby has some diaper rash and that they are currently treating it
with lifestyle modification and Desitin ointment every after the baby goes to the bathroom.

Objective

Vital Signs Vital Signs:

Temperature: 97.6 (Temporal) Blood Pressure: 78/42

O2 Saturation: 100% Weight: 12.5 lbs
Respiratory Rate: 45 Height: 23.5 inches
Heart Rate: 100 bpm Head Circumference: 39.5 cm
Clinical Growth chart Percentile: 53d Percentile on Weight, 76% on Height and 64th%
Percentile on the Head.

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 Systems/Body Areas of Physical Examination

General appearance:
W.M is active and energetic baby. Appears well kept. And is closely bonded with his mother,
looking at her occasionally for comfort. His clothes appear clean.

Physical Skin:
Examination Texture and appearance are within normal range, no pigmentation noted. Good skin turgor
especially of the calf muscles and skin over the abdomen. No Mongolian spots noted.
(PE)
HEENT:

Head: Normocephalic, no lesions. The baby’s head appears to have a flattened area on the right
side. Posterior and anterior fontanelle are open, no swelling nor depression noted.

Eyes: Symmetric with normal extraocular movements. Pupils 4 to 5 mm constricting.

Ears: Normal Pinna noted. No external abnormalities noted. Normal external canals and
tympanic membranes intact.

Nose: Normal nares; septum midline.

Throat: tonsils are normal in size, no exudate, inflammation noted of the anterior pillars, No teeth
noted, no tongue tie noted.

Neck:
Supple and no lymphadenopathy noted. Thyroid size is appropriate to age.

Pulmonary:
Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi.

Cardiovascular:
Regular rate and rhythm, S1S2 present with no murmurs appreciated, rubs, or gallops, good
pulses.

Respiratory:
Chest symmetric and clear to auscultation anteriorly and posteriorly.

Abdominal:
Positive bowel sound in all 4 quadrants, soft, nontender, and nondistended.

Skin:
No bruising, no rash noted.

Musculoskeletal:

No pain/discomfort noted with passive ROM of joints. Negative Ortolani or Barlow tests.

Male Genitalia:
The baby is uncircumcised, testes descended bilaterally, no hernia noted. No sores or lesions
noted. A mild erythematous skin noted around the genitalia.

Spine and Back:

Posture is appropriate to age, no rigidity noted. No pilonidal dimple nor cyst noted.

Neurologic:
Intelligence is appropriate to age, can recognize parents, has normal flexion, sucking, rooting
and Moro reflex. Anterior and posterior fontanelles are open, not distended nor sunken.

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Assessment
Diagnosis Diagnosis (Dx)

Positional Plagiocephaly ICD 10 Q 67.3

Positional plagiocephaly is a condition in which specific areas of an infant’s head develop an

abnormally flattened shape and appearance. Newborn infant skulls are very soft and malleable
to help ease them through the birth canal, so it is not unusual for newborns to have unusually
shaped heads, due to the pressure of birth. This condition usually resolves itself by six weeks of
age; however, some infants show a preference for sleeping or sitting with their heads turned
consistently in the same position, which may lead to positional plagiocephaly (Price, 2021).

Differential Diagnosis (DDX)

Congenital Muscular Torticollis (CMT) ICD 10 Q68.0

This is a condition in which an infant’s neck muscle is shortened causing the neck to twist.
Congenital means present at birth and torticollis means twisted neck. The condition is
sometimes called Wryneck. Lightening of the sternocleidomastoid (SCM) muscle, can result in
occipital flattening on the opposite side of the tight muscle. (Steinbrok &, Mortenson, 2008)

Unilateral Lambdoid Synostosis ICD 10 Q 75

It is a very rare condition, occurring in 1 in 150,000 newborn children (Steinbrok & Mortenson,
2008). The diagnosis is made by correlation of the occipital flattening with retraction of the ear
and forehead on the same side due to the generalized growth restriction of the fused suture.

Unilateral Coronal Synostosis ICD 10 Q 74.0

A premature fusion of a coronal suture causes forehead asymmetry and may also be present
combined with positional plagiocephaly. When there is significant asymmetry of the forehead
associated with occipital flattening, the possibility of unilateral coronal synostosis should be
considered. The diagnosis is made by examining orbital symmetry. From the front view, the
ipsilateral orbit tends to be higher and wider than the other orbit ( Steinbrok & Mortenson, 2008).

Plan

Plan Treatment Plan (Written as directive and numbered) include:

Educated parents on repositioning therapy. Educated parents on reducing the pressure on

the affected area through repositioning of the baby onto their abdomen for extended
periods of time throughout the day (Robinson & Proctor, 2009).

Educated patients that:

1. Repositioning for sleep, so that the baby moves his or her head more often.
2. Increased “tummy time” to improve neck strength and range of motion.

Parents are advised to come back to the clinic after a month. If it will not improve then they
will be referred to the Neurologist.

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 References:

Laughlin, J., Luersen, T., Dias, M., (2011). Prevention and management of Positional Skull
Deformities in Infants. Committee on Practice Ambulatory Medicine.
Retrieved from 1236.full.pdf (aappublications.org)

Positional Plagiocephaly. (2021). The Sydney Children’s Hospital Network. Retrieved from
Positional plagiocephaly | Sydney Children's Hospitals Network (nsw.gov.au)

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Price, A., (2021). Positional Plagiocephaly. American Association of Neurological Surgeons.
Retrieved from Positional Plagiocephaly – Symptoms, Diagnosis and Treatment
(aans.org)

Robinson, S., Proctor, M., (2009). Diagnosis and Management of Deformational Plagiocephaly.
Journal of Neurosurgery Pediatrics. 3(4): 284-95. Retrieved from
https://doi.org/10.3171/2009.1.PEDS08330

Steinbook, P., Mortenson, P., (2008). A Clinician’s Guide to Positional Plagiocephaly. BC

Children’s Hospital. Retrieved from BCCH034PlagiocephalyCliniciansGuideWeb1.pdf
(bcchildrens.ca)