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NP Student Name: Rebecca WoodChild’s Initials: TADOB: 04/09/2017Clinical Date: 6/15/19Age: 26 monthsPlace of Born: “here”Week Soap Project: W7Sex: M _x__F ___Type of Soap Note:Well child visit ____Sick visit __x__SUBJECTIVEHistorian: MotherPresent Concerns/CC: Mother states “Tommy isn’t himself” Child Profile:Activities of Daily Living(ageappropri ate): Mother helps child with ADLsSafetyPracti ces: Patient sits in car seat and mother denies access to guns. Changesi ndaycare/school/after-school care: Does not attend daycareDevelopmentalHistory: Mother reports the child is not hitting developmental milestones because of his down syndrome. Child does not say many words. HPI: 26-month-old male brought to the ED by his mother who states he has been complaining of abdominal pain for 2 days, vomited, is lethargic, diaphoretic, tachypneic, and has decreased urine output. Mother reports these symptoms started shortly after “falling out of bed.” Mother denies head trauma. Mother denies history of similar symptoms requiring medical attention. Medications: NonePMH:Allergies: NKDAChronic Illnesses/Major traumas: Down SyndromeHospitalizations/Surgeries: Atrial septal defect repairFamily Medical History Mother has anemia, father has no known history, one older sibling has asthma Social History Currentlivingsituation/partner/mari tal status:Mother, mother’s boyfriend, and 2 siblings Firearms in home:Mother denies guns in the home Safetystatus: Mother reports the child rides in a car seat and feels safe in the community
Pediatric SOAP NoteREVIEW OF SYSTEMSGeneral: Denies recent weight loss/gain, fever, fatigueReports increased irritability and low energyCardiovascular: Mother denies history of cardiac disease, murmurs, or palpitationsMother does report history of cardiomyopathy that “they fixed”Skin: Mother denies skin lesions, rash, hematomaRespiratory: Mother denies shortness of breath, cough, and wheezeReports tachypneaHead: Mother denies headache, lesions, and head trauma of any kindBreast: Mother denies discharge, lumps, swelling, andrednessEyes:Mother denies blurred vision, redness, and eye painGastrointestinal: Mother denies diarrhea and constipation Reports “rubbing his belly a lot” and one episode of vomiting, denies hemoptysisEars: Mother denies changes in hearing, discharge, or history of infection