16 years old patient with Pyelonephritis (FOCUS SOAP Note)

Assignment 2: Episodic Visit: Renal and/or Genitourinary Condition Focused Note

**Please make a FOCUS SOAP note on pyelonephritis**

 

information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.

 

To prepare:?

  • Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
  • Use the Episodic/Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.
  • Select a pediatric patient that you examined during the last 4 weeks. With this patient in mind, address the following in a Focused Note.

Assignment

  • Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Resources: Please use two of these resources on top of other resources you may use for references.

American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. (2011). Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595–610. https://doi.org/10.1542/peds.2011-1330

http://pediatrics.aappublications.org/content/128/3/595.full?sid=cc35023c-502d-474a-9856-bfb5e38eed54

Note: This article provides guidelines for diagnosing and managing urinary tract infections in febrile infants and young children. It also describes criteria for selecting appropriate treatment options.

Nicolle, L. E., Gopta, K., Bradley, S., Colgan, R., DeMuri, G. P., Drekonja, D., Eckert, L. O., Geerlings, S. E., Koves, B., Hooton, T. M., Juthani-Mehta, M., Knight, S. L., Saint, S., Schaeffer, A. J., Trautner, B., Wullt, B., & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83–e110.  

https://doi.org/10.1093/cid/ciy1121

Note: As you review this webpage, click on the PDF link to download the entire article.

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