NUR 636 Module 8 SOAP Note Example

SOAP Note: Febrile Urinary Tract Infection in a Fourteen-Month-Old Girl

[Student Name]

Southern New Hampshire University

NUR 636: Primary Care of Infants, Children and Adolescents

Module Eight SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Febrile Urinary Tract Infection in a Fourteen-Month-Old Girl

Fever without a source is one of the most frequent problems in toddler visits, and urinary tract infection is the most common serious bacterial infection hiding behind it. A pooled analysis found a urinary infection in roughly 7% of febrile children younger than two, with higher rates in girls and uncircumcised boys (Shaikh et al., 2008). Young children cannot describe dysuria, so the diagnosis depends on thinking of it and collecting urine correctly. A missed or delayed diagnosis can lead to kidney scarring, while overtreatment and unnecessary imaging carry their own harms. This SOAP note documents a fourteen-month-old with a febrile urinary tract infection and shows how the AAP guideline shapes each step, from collection method to imaging.

Subjective

Chief concern, from her father: "She's had a high fever for two days and she won't eat."

History of present illness: Lily is a fourteen-month-old girl with fever up to 39.6 degrees Celsius measured rectally for two days, relieved briefly by acetaminophen. She is fussy, drinking about half her usual milk and eating little. She has had five wet diapers in the past day, which her father says smell stronger than usual. No cough, runny nose, vomiting, diarrhea or rash. No sick contacts at her childcare. This is her first known fever above 39 degrees without a cold.

Past history: term birth, no hospital stays, immunizations up to date including pneumococcal and Hib series. No previous urinary infections. Constipation is occasional. Family history: her mother had vesicoureteral reflux as a child. Medications: acetaminophen as needed. Allergies: none.

Objective

Temperature 39.4 degrees Celsius rectal, heart rate 150, respiratory rate 30, oxygen saturation 99%. Weight 9.5 kg (50th percentile). She is irritable but consolable and makes eye contact. Mucous membranes moist, capillary refill under two seconds. Tympanic membranes gray and mobile, pharynx without exudate, lungs clear, no murmur. Abdomen soft, without masses or apparent tenderness. Normal female external genitalia without labial adhesions. Skin without rash. No meningeal signs.

Point-of-care urinalysis on a catheter specimen: leukocyte esterase 2+, nitrite positive, and on microscopy roughly 25 leukocytes in each high-power view, with bacteria throughout. The specimen was sent for culture. Forty-eight hours later E. coli had grown on the culture plate, well above 100,000 CFU/mL, susceptible to cephalexin, cefdinir and trimethoprim-sulfamethoxazole.

Assessment

1. Febrile urinary tract infection, presumed pyelonephritis, in a well-hydrated, nontoxic fourteen-month-old girl. Her probability was high before testing: she is female, has a temperature of 39 degrees or higher for two days and has no other source. The AAP guideline states that if antibiotics will be started, urine should be obtained by catheterization or suprapubic aspiration for culture, because bag specimens have a high rate of contamination, and that diagnosis requires both a urinalysis suggesting infection (pyuria, bacteriuria or both) and a single uropathogen reaching 50,000 CFU/mL or higher from a catheter or aspirate sample (Roberts, 2011). Lily meets both criteria.

2. Family history of vesicoureteral reflux, which increases the chance that she has reflux too.

Differential diagnoses considered: viral illness without localizing signs, which would not explain the pyuria and positive nitrite; occult pneumonia, unlikely with normal breathing and saturation; and occult bacteremia, now uncommon in fully immunized toddlers.

Plan

Treatment: cephalexin 75 mg/kg/day divided three times daily, about 240 mg per dose, for ten days, started after the catheter specimen was taken and adjusted if culture results require. The guideline found oral and parenteral antibiotics equally effective for children who are not toxic and can take oral medication, and recommends a total course of seven to fourteen days (Roberts, 2011). Hospital admission would be needed if she became unable to drink, vomited her doses or appeared toxic. Acetaminophen for comfort and frequent small drinks.

Imaging: a renal and bladder ultrasound is ordered to look for hydronephrosis, scarring or structural anomalies. A voiding cystourethrogram is not ordered after this first febrile infection; the guideline recommends it only if the ultrasound shows hydronephrosis, scarring or other findings suggesting high-grade reflux or obstruction, or after a second febrile infection. Her family history of reflux was discussed, and the plan will be revisited if the ultrasound is abnormal.

Prophylaxis: not started. In the RIVUR trial, trimethoprim-sulfamethoxazole prophylaxis in children with reflux roughly halved recurrent urinary infections but did not reduce renal scarring and increased the proportion of recurrences caused by resistant organisms (RIVUR Trial Investigators, 2014). With no known reflux, prophylaxis is not indicated.

Follow-up: phone check in 48 hours with culture results; visit if fever continues beyond 48 hours on treatment. Treat constipation if it recurs, since it contributes to repeat infections.

Severity and setting: she is alert, consolable, drinking enough to keep five wet diapers a day and can swallow medicine, so outpatient care is appropriate. Had she been younger than two months, toxic in appearance, dehydrated or unable to keep oral doses down, the plan would have been admission for intravenous antibiotics. Her rapid improvement is expected within 24 to 48 hours of starting an effective drug, and persistent fever beyond that point would prompt review of the culture sensitivities and consideration of an abscess or obstruction.

Family Education

Lily's father was told that she has a kidney infection, that oral medicine works as well as injections for children who can drink and keep medicine down, and that the full ten days must be given even after she feels better. He was told to return at once if she stops drinking, vomits repeatedly, becomes very sleepy or has fewer than three wet diapers a day. He was told that with any future fever without a clear cause, she should be seen within 48 hours so her urine can be checked, because early treatment of repeat infections helps protect the kidneys. He was reassured that bag samples are avoided only because they are often contaminated, not because catheter collection is routine for every visit.

Conclusion

Lily's fever had a treatable source that would have been missed without a urine test. Collecting urine by catheter, confirming infection with both urinalysis and culture, treating with oral cephalexin, obtaining a renal and bladder ultrasound and reserving a voiding cystourethrogram for abnormal results or recurrence follows the AAP guideline and avoids both undertreatment and unnecessary testing.

References

RIVUR Trial Investigators. (2014). Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine, 370(25), 2367-2376. https://doi.org/10.1056/NEJMoa1401811

Roberts, K. B. (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

Shaikh, N., Morone, N. E., Bost, J. E., & Farrell, M. H. (2008). Prevalence of urinary tract infection in childhood: A meta-analysis. Pediatric Infectious Disease Journal, 27(4), 302-308. https://doi.org/10.1097/INF.0b013e31815e4122