Pediatric SOAP note Name: M.P. Date: June 11, 2019 Sex: Female Age/DOB/Place of Birth: 12, 11/5/2006 SUBJECTIVE Historian: Patient and Mother Present Concerns/CC : “Fever and cough” Child Profile : Denies any sexual history. Currently in middle school, and plays soccer on her school’s team. Wears proper safety equipment with sports, and reports wearing a helmet when riding her bicycle. No history of developmental delays or problems. HPI: Patient presents with complaints of fever, headache and “feeling tired” and runny nose. Mother states that symptoms started 3 days ago. Reports fever got as high as 103 and has a productive cough. She has taken Ibuprofen and guaifenesin for symptoms. Denies getting the flu shot this year. Medications : Not currently on medication PMH: Allergies: None Medication Intolerances: None Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: None reported Immunizations: Current on vaccinations, but did not receive flu vaccine this season. Family History: Mother: HTN, Hypothyroidism Father: Smoker, HTN, HLD Social History Patient lives at home with her parents and younger sister, age 7. She is currently in middle school and goes to a public school for education. She plays soccer through her school. She denies any alcohol, smoking or drug use. When she grows up she wants to work with animals. ROS General Reports feeling achy all over, fever. Denies weight loss. Cardiovascular Denies any known history of heart murmurs. No cyanosis. Skin Denies any rash, irritation, cuts or bruises. Respiratory Reports cough with mild phlegm production. Denies any SOB, wheezing or difficulty breathing. Eyes Denies vision problems or using glasses. Gastrointestinal Reports decrease in appetite. Denies any history of acid-reflux, nausea, vomiting, or diarrhea. Ears Denies hearing loss, tinnitus or pain in ears. Genitourinary/Gynecological Denies any difficulty, burning or frequency of urination. Patient has not yet started menses.
Pediatric SOAP note Nose/Mouth/Throat Denies congestion, sore throat, difficulty swallowing. Per mom, patient has a runny nose.
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- Summer '17