Pediatric SOAP Note #3- case 4583-20240525-006

Please provide the requested information on the template and enter the information on the template form attached. 

-Patient: 9 year old white male

Date of Birth: May 1, 2015

-chief complaint: penile redness and itching

-history of present illness: patient’s mother reports that her son has been experiencing redness and itching on the penile area for the past three days. There is no associated pain or discharge. No recent changes in soap, detergent, or clothing. The child has not been exposed to any new foods. Had a sleepover at a friends house a few days prior to the symptoms. No recent travel history. 

history: right arm fx (2019), asthma (2017)

Allergies: shellfish 

Medications: Multivitamin daily

 Plan: 

1. Discussed with the patient and his mother about proper hygiene, including gentle cleaning with warm water and avoiding harsh soaps or detergents.
2. Gently retract the foreskin (if not circumcised) and clean underneath with water.
3. Advise on the use of loose-fitting, breathable cotton underwear to prevent moisture buildup. Encourage the patient to avoid scratching the area.
4. Educate the mother to watch for signs of infection such as increased redness, swelling, pain, or discharge, and to seek medical attention if these occur.
5. If symptoms persist or worsen, return for a follow-up appointment in one week.
6. Schedule a follow-up appointment in 7-10 days to monitor progress and ensure the infection is resolving.

Treatment:( please be specific with medication dose, route, frequency) Topical Antibiotic ointment (bacitracin) and oral Metronizadole 

ICD code- N48.1 Balanitis

CPT code- 99213

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