Pediatric SOAP Note NP Student Name: Kayla Stevens Child’s Initials: LS DOB: 06/12/2016 Clinical Date: 07/02/2019 Age: 3 Place of Born: Douglas, GA Week Soap Project: W10 Sex: M __X_ F ___ Type of Soap Note: Well child visit ____ Sick visit __X__ SUBJECTIVE Historian: Parent Present Concerns/CC: "I think he has tonsillitis again" Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living ( a g e a pp r o p r i at e) : The toddler is toilet trained but does continue to wear pull ups as he does still have “accidents”. The toddler feed himself with a spoon and fork. The toddler can drink from a cup. The toddler brushes teeth with help. The toddler does require help dressing. S a f e ty Pr act i c e s : Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seat, mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure Nutrition: Mother states that the child drinks 2% milk approximately 2 cups per day. States that the child drinks juice and soda occasionally. States the child is a picky eater and is currently only wanting to eat “mac and cheese” but she does try to ensure that he has vegetables and well balanced meals. C h a n ge s i n d a y ca r e / s c h ool /a f t e r-s c h oo l ca r e : No changes. Attends day care while mother and father work during the day. Sleep: The toddler sleeps with mother and father in their bed. The toddler usually goes to sleep around 9pm and wakes up at 8 am. Mother reports toddler sleeps through the night. Does take one nap per day. S p o r t s / ph y s ical ac t i vi t y : NA D e v elo p m e n tal History : - Gross motor: Walks up/down steps, able to kick a ball with direction, jumps with both feet, can catch a ball, rides a tricycle, dresses with assistance - Fine motor: Scribbles on paper, colors pages, can build a tower of 9-10 cubes, puts on shoes, uses scissors, copies circle - Cognitive: Follows simple commands, names items in pictures, knows colors, knows shapes, can count to 10. - Social/Emotional: plays well alongside other children, does occasionally have a difficult time sharing toys, enjoys pretend play such as pretending to be a policeman or cowboy - Communication: Speaks in 3-4 word sentences. S ex u al H i s t o r y (i f a p p r o p r i at e ) :NA HPI: The patient is a 3-year-old white male who presents with his mother secondary to fever and vomiting X 2 days. States she thinks tonsils are swollen and this gagged him and caused vomiting. Mother states they have been rotating Tylenol and ibuprofen at home for fever. States she fears it is tonsillitis again, states this is the 3rd time the child has had it this year. Denies any further complaints at present. Medications : No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for his fever.
- Summer '17
- Tonsillitis, Upper respiratory tract, Upper respiratory tract infection