Valeria Klimack
Miami Regional University
Date of Encounter: 07/06/2024
Preceptor/Clinical Site: / Pediatrics Consultants of kendal
Clinical Instructor: Dr. Theresa Acosta Avila
Soap Note # ____ Main Diagnosis Patient initials: A.L.
Age: 4 y/o
Race: N/A
Gender: Male
Insurance: N/A
Information Source: Given by patient’s mother
Allergies: NKA.
Medication History: ibuprofen if needed for pain or discomfort; oral and topical antibiotics prescribed for 7 days
Family History: None Allergies: NKA.
Medication History: ibuprofen if needed for pain or discomfort; oral and topical antibiotics prescribed for 7 days
Family History: None
Past medical History (PMH): None
Immunization status: None
Developmental stage: Preschool Age (3-5 years).
Hospitalization: No previous hospitalization.
History of mental illness/personality disorders: None.
Physical trauma/falls: None.
Surgeries: No previous history
Exercise: none
Diet:none.
Social History: Lives with mother and grandmother
Last annual physical exam: N.A
SUBJECTIVE
Chief complaint: “”My baby has some redness and swelling of his penis.”
History of present illness (HPI): The patient is a 4-year-old male who is brought today for consultation by his mother and grandmother. Parent reports patient has been experiencing redness and swelling of his glans since a few days ago, denies presence of pus. She states she is worry because it never has been like that before and he has been grabbing it a lot.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Parent denies fever, malaise.
NEUROLOGIC: Parent denies seizure, vision changes, headaches.
HEENT : Mother reports no head, eye, ear, nose, or throat concerns.
CARDIOVASCULAR: No chest pain, palpitations or complains
RESPIRATORY: Mother denies presence of cough, shorthness of breath or congestion.
GASTROINTESTINAL Mother reports no appetite loss, denies stomach discomfort, nausea, vomiting, or constipation.
GENITOURINARY: Urinary habits unchanged. The patient urinates painlessly.
MUSCULOSKELETAL: No stiffness or soreness.
INTEGUMENTARY: Mom states inflammation and redness in the glans penis but no other skin issues.
OBJECTIVE
Physical Exam
Vitals Signs: Weight: 42.41 Lbs Height: 40 in BMI: 18.5. > 95th percentile
GENERAL APPEARANCE: The patient plays like a well-fed, hyperactive youngster. SKIN: The glans penis is erythematous and edematous. HENT: No head, eye, ear, nose, or throat problems. CARDIOVASCULAR: Heart rate and rhythm are within normal limits and regular. RESPIRATORY: No respiratory distress, clear lung sounds. GASTROINTESTINAL: No complaints. GENITOURINARY: Swelling and redness of the glans penis. No discharge. MUSCULOSKELETAL: The joints and movements are normal and not painful. NEUROLOGIC: Hyperactive
ASSESSMENT
Balanitis ICD-10 Code: N47.1: Balanitis involves inflammation of the glans penis; this would correspond to the redness and hardness, but no exudate in an infection context (Wray et al. , 2020). Despite this, documentation reveals that patient’s past medical history, physical examination, and absence of systemic signs such as fever and dysuria would rather portray a local inflammation that is not a systemic infection or another dermatosis. Conditions such as poor hygiene, irritation due to chemicals or soaps, and fungal or bacterial infections can cause balanitis; this could have been a possibility in this sexually active patient given the age and testicular look. Therefore, the best diagnosis when clinical presentation is into consideration is balanitis.
Differential diagnosis
Contact Dermatitis (ICD-10: L25.9): Glans penis inflammation may result from allergies or irritants. However, when questioned, the patient’s mother denied any recent detergent, soap, or allergy changes that may induce dermatitis. If there is no itching, burning, or history of such episodes with specific contacts, contact dermatitis is unlikely (Litchman et al., 2023).
Urinary Tract Infection (ICD-10: N39.0): UTI was evaluated because urethritis may cause glans penis redness and swelling. However, the patient did not experience UTI symptoms such dysuria, frequency, urgency, fever, or stomach pain (Mancuso et al., 2023). Genital examination showed no discharge or urethral discomfort, ruling out this diagnosis.
Candidal Balanitis (ICD-10: B37.3): Candidal balanitis, a fungal glans penis infection, was researched since it is common in young children, especially after poor hygiene or antibiotic use. However, candidal infections do not cause cottage cheese-like discharge or satellite lesions (Freedman, 2023). Candidal balanitis was reduced by the patient’s lack of recent antibiotic use and immunological dysfunction.
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PLAN
No labs /Diagnostic test ordered Labs and Diagnostic Test to be ordered (if applicable)
• Swab Culture and Sensitivity: A glans penis swab culture may detect the inflaming bacteria or fungi. This test is beneficial if antibiotics or antifungals fail or if serious infection is present.
• Allergy Testing: Use patch testing for common allergens if contact dermatitis persists.
Pharmacological treatment:
– Topical Antibiotic Ointment (Dallo et al., 2023)
Medication: Bacitracin ointment
Dosage: Apply a small amount to the affected area (glans penis) three times daily for 7 days.
Non-pharmacological measures:
· Good hygiene: Tell the patient’s caregivers to wash their genitalia with mild soap and water. Keeping clean prevents smegma and balanitis.
· Avoid allergies and irritants: Avoid harsh soaps, detergents, and fragrances that may sting. It lowers inflammation and promotes skin healing.
· Many times a day, apply warm compresses to the affected area. It may reduce inflammation, enhance circulation, and treat pain without medications.
· Loose Clothing: Cotton underwear and garments that fit loosely reduce friction and ventilation. It avoids irritation and keeps the glans penis dry.
Education:
· Show caregivers how to regularly wash the private region with water and mild soap. Balanitis may be avoided by being clean and dry.
· Avoid soaps, cleansers, and perfumes that might irritate the glans penis’s skin. Use fragrance-free cleaning and bath products.
· Teach caregivers how to use external antibiotics like bacitracin cream and ensure medication is administered as directed.
· Encourage medical appointments to monitor health and treat symptoms. Discuss worsening symptoms including fever, pain, or swelling.
Referral/Follow up: To evaluate therapy response and ensure symptom elimination, schedule a follow-up appointment in one week. Balanitis symptoms may persist after therapy if the reason is unknown. Contact a pediatric urologist. Give caregivers clear instructions on when and how to seek urgent medical help for worsening or new symptoms.
**Valeria Klimack**
**Miami Regional University**
**Date of Encounter: 07/06/2024**
**Preceptor/Clinical Site: Pediatrics Consultants of Kendal**
**Clinical Instructor: Dr. Theresa Acosta Avila**
**Soap Note # ____ Main Diagnosis Patient initials: A.L.**
**Age:** 4 y/o
**Race:** N/A
**Gender:** Male
**Insurance:** N/A
**Information Source:** Given by patient’s mother
**Allergies:** NKA
**Medication History:** Ibuprofen if needed for pain or discomfort; oral and topical antibiotics prescribed for 7 days
**Family History:** None
**Past Medical History (PMH):** None
**Immunization Status:** Up to date
**Developmental Stage:** Preschool Age (3-5 years)
**Hospitalization:** No previous hospitalization
**History of Mental Illness/Personality Disorders:** None
**Physical Trauma/Falls:** None
**Surgeries:** No previous history
**Exercise:** None
**Diet:** None
**Social History:** Lives with mother and grandmother
**Last Annual Physical Exam:** N/A
**SUBJECTIVE**
**Chief Complaint:** “My baby has some redness and swelling of his penis.”
**History of Present Illness (HPI):** The patient is a 4-year-old male brought in by his mother and grandmother. They report that the patient has been experiencing redness and swelling of his glans for a few days. They deny the presence of pus but note that he has been grabbing the affected area frequently.
**Review of Systems:**
– **CONSTITUTIONAL:** Denies fever, malaise
– **NEUROLOGIC:** Denies seizures, vision changes, headaches
– **HEENT:** No head, eye, ear, nose, or throat concerns
– **CARDIOVASCULAR:** No chest pain, palpitations, or complaints
– **RESPIRATORY:** Denies cough, shortness of breath, or congestion
– **GASTROINTESTINAL:** No appetite loss, stomach discomfort, nausea, vomiting, or constipation
– **GENITOURINARY:** Urinary habits unchanged; urinates painlessly
– **MUSCULOSKELETAL:** No stiffness or soreness
– **INTEGUMENTARY:** Inflammation and redness in the glans penis, no other skin issues
**OBJECTIVE**
**Physical Exam:**
– **Vital Signs:**
– Weight: 42.41 lbs
– Height: 40 in
– BMI: 18.5 (> 95th percentile)
– **General Appearance:** Appears well-fed, hyperactive
– **Skin:** Erythematous and edematous glans penis
– **HENT:** No head, eye, ear, nose, or throat problems
– **Cardiovascular:** Heart rate and rhythm within normal limits and regular
– **Respiratory:** No respiratory distress, clear lung sounds
– **Gastrointestinal:** No complaints
– **Genitourinary:** Swelling and redness of the glans penis, no discharge
– **Musculoskeletal:** Normal joints and movements, not painful
– **Neurologic:** Hyperactive
**ASSESSMENT**
**Primary Diagnosis:** Balanitis (ICD-10 Code: N47.1) – Inflammation of the glans penis, characterized by redness and swelling without discharge. Likely due to poor hygiene, irritation, or infection.
**Differential Diagnosis:**
1. **Contact Dermatitis (ICD-10: L25.9):** Unlikely due to the absence of recent exposure to allergens or irritants and lack of itching or burning.
2. **Urinary Tract Infection (ICD-10: N39.0):** Unlikely due to the absence of dysuria, frequency, urgency, fever, or stomach pain.
3. **Candidal Balanitis (ICD-10: B37.3):** Unlikely due to the absence of characteristic discharge and lack of recent antibiotic use.
**PLAN**
**Diagnostics:**
– No immediate labs or diagnostic tests ordered
– Consider swab culture and sensitivity if symptoms persist or worsen
– Consider allergy testing if contact dermatitis is suspected
**Pharmacological Treatment:**
– **Medication:** Bacitracin ointment
– **Dosage:** Apply a small amount to the affected area (glans penis) three times daily for 7 days
**Non-Pharmacological Measures:**
– Emphasize good hygiene: Clean genitalia with mild soap and water regularly
– Avoid irritants: Avoid harsh soaps, detergents, and fragrances
– Apply warm compresses: Several times a day to reduce inflammation and pain
– Loose clothing: Wear cotton underwear and loose-fitting clothes
**Education:**
– Teach caregivers proper genital hygiene
– Avoid potential irritants
– Proper application of bacitracin ointment
– Importance of follow-up appointments
– When to seek urgent medical help (fever, increased pain, swelling)
**Referral/Follow-Up:**
– Schedule a follow-up appointment in one week to assess treatment response
– Consider referral to a pediatric urologist if symptoms persist
**References**
– Dallo, M., Patel, K., & Hebert, A. A. (2023). Topical Antibiotic Treatment in Dermatology. *Antibiotics, 12*(2), 188. [https://doi.org/10.3390/antibiotics12020188](https://doi.org/10.3390/antibiotics12020188)
– Freedman, D. (2023). Balanitis. *Springer EBooks*, 89–99. [https://doi.org/10.1007/978-3-031-15130-9_8](https://doi.org/10.1007/978-3-031-15130-9_8)
– Litchman, G., Nair, P. A., Atwater, A. R., & Gossman, W. G. (2023). Contact dermatitis. PubMed; StatPearls Publishing. [https://www.ncbi.nlm.nih.gov/books/NBK459230/](https://www.ncbi.nlm.nih.gov/books/NBK459230/)
– Mancuso, G., Midiri, A., Gerace, E., Marra, M., Zummo, S., & Biondo, C. (2023). Urinary Tract Infections: The Current Scenario and Future Prospects. *Pathogens, 12*(4), 623. [https://doi.org/10.3390/pathogens12040623](https://doi.org/10.3390/pathogens12040623)
– Wray, A. A., Velasquez, J., & Khetarpal, S. (2020). Balanitis. PubMed; StatPearls Publishing. [https://www.ncbi.nlm.nih.gov/books/NBK537143/](https://www.ncbi.nlm.nih.gov/books/NBK537143/)
References
Dallo, M., Patel, K., & Hebert, A. A. (2023). Topical Antibiotic Treatment in Dermatology. Antibiotics, 12(2), 188. https://doi.org/10.3390/antibiotics12020188
Freedman, D. (2023). Balanitis. Springer EBooks, 89–99. https://doi.org/10.1007/978-3-031-15130-9_8
Litchman, G., Nair, P. A., Atwater, A. R., & Gossman, W. G. (2023). Contact dermatitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459230/
Mancuso, G., Midiri, A., Gerace, E., Marra, M., Zummo, S., & Biondo, C. (2023). Urinary Tract Infections: The Current Scenario and Future Prospects. Pathogens, 12(4), 623. https://doi.org/10.3390/pathogens12040623
Wray, A. A., Velasquez, J., & Khetarpal, S. (2020). Balanitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537143/
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