PEDIATRIC FILLABLE SOAP NOTE TEMPLATE Patient Initials: T.A. Date of Encounter: 4/6/2019 Sex: M Age/DOB/Place of Birth: 26 months SUBJECTIVE Historian: Mother Present Concerns/CC: “Tommy isn’t himself today. He has been whining and refusing to eat. I think he is saying that his tummy hurts. When I took a look at his tummy it has a big bruise.” Child Profile: Diagnoses with Downs Syndrome. Height: 28" = significantly lower than the 5th percentile. Weight: 22pounds = less than 5th percentile. BMI: 19.7. Mother’s boyfriend and on occasion neighbors watch Tommy while his mother is at work. There is an infant and an older child in the house. HPI: (must include all components - OLD CARTS) Mother reports onset of abdominal pain was two days ago which she believes happened when he fell off of the bed while taking a nap at that time. He has bruising to his epigastric area. He is refusing to eat. He rubs his abdomen and saying his tummy hurts. He is not sleeping well and is irritable. He had an episode of vomiting last night. He is clammy, pale, and listless. He has tachypnea, decreased oxygen saturation, tachycardia, and hypotension. This is the first treatment sought. Medications: None 1 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PMH: Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: AV septal repair as an infant Immunizations: Mother reports up to date but might have missed last ones. Will investigate further. Family History (please identify all immediate family) Unknown at this time Social History Lives with biological mother, step-father, one older sibling, and one younger half-sibling. Mother and step-father smoke, exposure to second hand smoke. Review of Systems (ROS) 2 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE General Has fatigue. Denies fever, chills, night sweats. Decreased energy level Cardiovascular Denies edema Skin Delayed healing of wounds around wrist, rash on perineum, bruising to abdomen, bleeding or skin discolorations on abdomen. Respiratory Denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx. Eyes Denies corrective lenses, blurring, visual changes of any kind Gastrointestinal Has abdominal pain, nausea, and vomiting.
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- Summer '17
- tommy, NSG6435 Week 7 Discussion