Pediatric SOAP Note Name: KP Date:3/11/19 Sex: F 8 years, 10/13/2010 Lake Orion, MI SUBJECTIVE Historian: Mother Jennifer Child Profile: Eight-year-old child presented to clinic with ill looking appearance. Mom stated that her child was not feeling well for past 4 days. Complaints include fever, sore throat, productive cough and fatigue. She suspects the child might have an infection. HPI: The mother states my daughter has been ill for past 4 days. She has fever, sore throat and productive cough. 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 looks tired and ill but looks well nourished and well groomed. She is alert and oriented and responds to questions. Medications : Ibuprofen for fever for past 2 days. PMH: KP was a planned pregnancy with prenatal care beginning at approximately 12 weeks 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 with no reported illnesses or infectious diseases. Allergies: NKA Medication Intolerances: None Hospitalizations/Surgeries: No surgical history or hospitalizations reported.
Pediatric SOAP Note Family History Mother – Living Healthy Maternal Grandmother- Stroke Maternal Grandfather- CAD, HTN Social History KP is currently living with her father and mother in their house. KP goes to school regularly. She is in third grade. She likes to interact with children of her age. She plays soccer and does swimming classes on Wednesdays. She is doing well at school. Mom denies alcohol or substance use by her or child’s father. ROS General: Mother reports the child is very ill now, she feels tired all the time. She consumes healthy diet daily and drinks water. Mom denies weight changes, or sleep issues. Cardiovascular Pt. Mother denies any previous heart conditions, no chest pain, no palpitations, no dizziness, no chest pressure, no blue or cold fingers. Skin Mother denies a history of birth marks, skin lesions, no rashes, no issues with fingernail or hair growth. Skin is warm to touch due to fever. Skin is dry and healthy. Respiratory Mother reports child had fever and productive cough with yellow mucoid sputum for the past 4 days.
Pediatric SOAP Note Eyes Mother denies eye pain, blurry vision, or redness. Gastrointestinal Mother denies any nausea, vomiting, diarrhea, abdominal pain, no blood in stools, no constipation, no bloating or tarry stools. Ears Mother denies ear pain, hearing loss, or drainage. Genitourinary/Gynecological: Mother states child has normal bowel and bladder pattern. No urgency, frequency burning, change in color of urine.
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