Pediatric SOAP NoteName: MsDate:3/5/19Sex: F10years, 2/13/2009/Lake Orion, MISUBJECTIVEHistorian: Mother MarianChild Profile:Healthy looking 10-year-old female child presents to the clinic with mother. The mother states my daughter is ill for 4 days. She has fever and chills of 101.F, with soar throat and runny nose and sounds congested. Mother says due to this she is very tired and cannot go to school.HPI: The mother states my daughter is ill for 4 days. She has fever and chills of 101.F, with sore throat and runny nose and sounds congested. Mother says due to this she is very tired and cannot go to school. The patient has no previous medical history requiring treatment or chronic care. The child is alert, sitting in chair, well-nourished and well groomed. Medications: NonePMH:Ms was a planned pregnancy with prenatal care beginning at approximately 7weeks gestation. Mom was healthy during pregnancy, she did not smoke, consume alcohol or illegal drugs. She reports no illness during pregnancy. The only medications she took was a daily prenatal and folic acid. She had a 29-pound weight gain during pregnancy, delivered vaginally with no complications. Child is healthy withno reported illnesses or infectious diseases. Allergies: NKAMedication Intolerances: None Hospitalizations/Surgeries: No surgical history or hospitalizations reported.
Pediatric SOAP NoteFamily HistoryMother – Living HealthyMaternal Grandmother- StrokeMaternal Grandfather- CAD, HTN Social History Mother is currently living with her husband. Mother reports no one smokes around child. Mother currently works as an elementary school teacher, Ms goes to school regularly. Mom denies alcohol or substance use by her and father. Mom reports she has never been abused physically or sexually and feels safe in her home and community.ROSGeneral Mother reports the child is very ill now, but she is very active at home, has a fair appetite. She consumes healthy diet daily and drinks water. CardiovascularPt. Mother denies any previous heart conditions, no chest pain, no palpitations, no dizziness, no chest pressure, no blue or cold fingers. SkinMother denies a history of birth marks, skin lesions, no rashes, no issues with fingernail or hairgrowth. Skin is warm to touch due to fever.RespiratoryMother reports child has rhinitis for 4 days with clear discharge from nose, congestion present. No breathing difficulties, blue spells, coughing, snoring at night or sleep apnea.
Pediatric SOAP NoteEyesMother denies eye pain, blurry vision, or redness. GastrointestinalMother denies any nausea, vomiting, diarrhea, abdominal pain, no blood in stools, no constipation, no bloating or tarry stools. EarsMother denies ear pain, hearing loss, or drainage. Genitourinary/GynecologicalMother states child has normal bowel and bladder pattern. No urgency, frequency burning, change in color of urine.
You've reached the end of your free preview.
Want to read all 13 pages?
- Summer '17