Name: TA Date: 7/19/19 Sex: Male 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: Ill appearing 26-month-old, male with a history of Downs’s syndrome. The mother states overall he is healthy, very active and playful.” She reports that “due to his Downs syndrome, he has a growth and speech delay, he does not talk much, says very little words, and does not pick things up very quickly.” She admits that he is very clumsy, always falling, tripping, or bumping into things. Although she denies prior injuries that required medical attention. She states that he is normally a good boy, who eats his meals, drinks an adequate amount of water and sleeps well during the night. 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: Mother and a 26-month-old boy with Downs’ syndrome present to ER with a complaint of abdominal pain for two days after a fall from the bed during a nap. She states he is not eating or drinking but has vomited once. He is listless and lethargic, has a bruise on his abdomen, tachypnea, and having dark colored urine. His abdomen is distended and tender and guarding upon assessment. According to the mother, these symptoms started shortly after the incident. This is the first treatment sought. He has a history of Down syndrome with global developmental delay and a corrected atrial-septal defect with transient, postoperative congestive heart failure. Medications : None PMH: Mother with normal birth and had no problems or complications during pregnancy. Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: Atrioventricular septal defect, transient CHF, heart murmur, denies any trauma Hospitalizations/Surgeries: Atrioventricular septal defect repair Immunizations: Mother reports up to date but might have missed last ones. Will investigate further. Pediatric SOAP Note
Family History Mother - Anemia Father - Unknown 5-year-old – Asthma 6-month-old – Healthy Social History Mother is single but has a boyfriend. She graduated from high school and is employed, as a cashier at a local retail shop. She does not make a lot of money and can’t afford daycare, uses her neighbor and boyfriend for childcare. She tries not to use the boyfriend as much since the kids are “whiney” and bother him. Patient is exposed to second-hand smoke. Mother and boyfriend both smoke but smoke in separate rooms away from the kids. She denies any substance use/abuse, ETOH, and marijuana. Mother feels safe in community and surrounding neighborhood.
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- Summer '17