Pediatric SOAP Note SUBJECTIVE Historian: Mother Present Concerns/CC : “Tummy ache.” Child Profile : Ill appearing 26-month-old, male with a history of Downs’s syndrome. The mother states overall he is healthy, very active and playful.” She reports that “due to his Downs syndrome, he has a growth and speech delay, he does not talk much, says very little words, and does not pick things up very quickly.” She admits that he is very clumsy, always falling, tripping, or bumping into things. Although she denies prior injuries that required medical attention. She states that he is normally a good boy, who eats his meals, drinks an adequate amount of water and sleeps well during the night. HPI: (must include all components) Mother and a 26-month-old boy with Downs’ syndrome present to ER with a complaint of abdominal pain for two days after a fall from the bed during a nap. She states he is not eating or drinking but has vomited once. He is listless and lethargic, has a bruise on his abdomen, tachypnea, and having dark colored urine. His abdomen is distended and tender and guarding upon assessment. According to the mother, these symptoms started shortly after the incident. He has a history of Down syndrome with global developmental delay and a corrected atrial-septal defect with transient, postoperative congestive heart failure. Medications : None PMH: Mother with normal birth and had no problems or complications during pregnancy. Allergies: None Medication Intolerances: None Chronic Illnesses/Major traumas: Atrioventricular septal defect, transient CHF, heart murmur Denies any trauma Hospitalizations/Surgeries: Atrioventricular septal defect repair Immunizations: Immunizations up-to-date DTaP x 5, Hep-A x2, Hep-B x3 HIB x4, MMR x2, PCV7 x4, IPV x4, VZV x2, FLU x2 Family History Mother – Anemia 5- year –old – Asthma 6-month-old – Healthy Father- unknown Social History Mother is single but has a boyfriend. She graduated from high school and is employed, as a cashier at a local retail shop. She does not make a lot of money and can’t afford daycare. So she uses her neighbor and boyfriend for childcare. She tries not to use the boyfriend as much since the kids are “whinny” and bothers him. T.A. is exposed to second-hand smoke. Mother and boyfriend both smoke but smoke in separate rooms away from the kids. She denies any substance use/abuse, ETOH, and marijuana. Mother feels safe in community and surrounding neighborhood . ROS General Mother reports the patient is listless, lethargic, fatigued, and dehydrated. He has a poor appetite, and not tolerating or drinking liquids. Denies fevers, or changes in weight, recent illness, or insomnia. Cardiovascular Admits to a history of a heart defect. Denies dizziness, chest pain, pressure, palpations, and blue or cold fingers Skin Mother admits to being sweaty and having pale, clammy skin, with a large bruise on his abdomen.
You've reached the end of your free preview.
Want to read all 6 pages?
- Summer '17
- abdominal trauma, Peritonitis, NSG6435 Week 7 Discussion