Using the following case create a soap note:
Patient is a two years old male who was brought for consultation by his mother. She estate he started developing a painful lesion on his right lower limb since like a week ago, which just started as a bite. On the physical examination, there is redness and induration the right inner tight tender on palpation with well limited edges. CBC was performed in office which reported and slighted elevated white blood cell count. We recommended a dose of Rocephin IM stat, we marked borders to evaluate tomorrow if any change. We also recommended ibuprofen prn fever and pain. ..
Include in the plan possible antibiotic if it would be prescribe for when patient returns to home
DIAGNOSIS: L03.115 – CELLULITIS OF RIGHT LOWER LIMB
**SOAP Note**
**Patient:** 2-year-old male
**Date:** [Insert Date]
**Provider:** [Your Name/Title]
**Subjective:**
The patient was brought in by his mother, who reported that the child developed a painful lesion on his right lower limb approximately one week ago. The lesion initially appeared to be a bite. The mother noted that the area has become increasingly red and swollen, and the child has been experiencing pain.
**Objective:**
– **Physical Examination:**
– **Right Lower Limb:** Redness and induration noted on the right inner thigh. The area is tender on palpation with well-defined borders.
– **Vital Signs:** [Insert Vital Signs Here, e.g., temperature, heart rate, respiratory rate, etc.]
– **Laboratory Results:**
– CBC: Slightly elevated white blood cell count.
**Assessment:**
– **Diagnosis:** Cellulitis of the right lower limb (ICD-10: L03.115). The clinical presentation and elevated white blood cell count are consistent with cellulitis, likely secondary to an initial insect bite.
**Plan:**
1. **Immediate Management:**
– **Antibiotic Therapy:** Administered a dose of Rocephin (ceftriaxone) 50 mg/kg IM stat to address the infection.
– **Pain and Fever Management:** Recommended ibuprofen 10 mg/kg orally every 6-8 hours as needed for fever and pain.
– **Monitoring:** Marked the borders of the lesion to evaluate for changes in size or appearance over the next 24 hours.
2. **Follow-up:**
– **Reevaluation:** Patient should return for a follow-up visit tomorrow to assess any changes in the lesion’s size, borders, and overall condition.
– **Continued Antibiotic Therapy:** If cellulitis persists or worsens, or if there is no improvement, initiate oral antibiotics. Consider options such as:
– **Amoxicillin-Clavulanate (Augmentin):** 20-40 mg/kg/day divided into 2-3 doses, depending on severity.
– **Cephalexin:** 25-50 mg/kg/day divided into 2-4 doses, as an alternative if the patient has a penicillin allergy.
3. **Patient Education:**
– Instruct the mother to monitor for signs of worsening infection, including increased redness, swelling, warmth, or fever.
– Advise on proper wound care and hygiene to prevent further infection.
4. **Referral/Consultation:**
– Consider referral to a pediatric infectious disease specialist if the patient does not improve with initial treatment or if there are concerns about complications.
**Follow-Up Appointment:**
– Schedule a follow-up visit for [insert date], or sooner if symptoms worsen or new symptoms develop.
**Signature:**
[Your Name, Title]
[Your Contact Information]
—
**Attachments:**
– SOAP Note Sample for Pediatric Patients (as per provided document)
**Note:** Ensure to adjust the dosage and treatment plans based on the patient’s specific needs and response to initial treatment.
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