NUR 6435 WEEK 7 COMPREHENSIVE SOAP PROJECT.docx - PEDIATRIC FILLABLE SOAP NOTE TEMPLATE STUDENT NAME Tiffany Swanson Patient Initials TA DATE OF

NUR 6435 WEEK 7 COMPREHENSIVE SOAP PROJECT.docx - PEDIATRIC...

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STUDENT NAME: Tiffany SwansonDATE OF ASSIGNMENT: 12/02/2019Patient Initials:TADate of Encounter: 10/05/2015Sex:MaleAge/DOB/Place of Birth:Unknown place of brith8/5/2013- 26 monthsSUBJECTIVEHistorian:MOMPresent Concerns/CC:"He isn’t himself. He is been whining alot and refusing to eat. He has been rubbing his tummy”Child Profile:26 month old Caucasian male with downs sundrome Mom atTEA “his milestones are different. He can say a few words and he started walking later than his others two siblings for sure”. Mom also reports he holds on tp furniture while walking and still wears diapers. Patient had a normal birth and mom denies pregnancy issues. Patient is not in day and he is watched by the father ofhis youngest sibling when mom is at work. HPI: (must include all components - OLD CARTS)The patient is 26 months old male with Down syndrome with a history of congestive heart failure, and ASD s/p surgical . Came into the emergency room with his mother with complaints of abdominal pain x two days, has vomited x1. Patient is lethargic, diaphoretic, breathing rapidly and has decreased urine output. Abdomen grossly distened with a large bruise approximately 10mcm in the lower portion.O-2 DAYS agoL-ABDOMEND-ConstantC-PAIN-UNABLE TO ASSESSCHARATERISTICAA touching makes it worse- Nothing given to alleviateR-Pain does not moveT-NoneS-6/10 per momPEDIATRIC FILLABLE SOAP NOTE TEMPLATE1| P E D I A T R I C S O A P N O T E
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Medications: (List with reason for meds)None PMH:Boorn with Downs syndromeCHFCrdiac surgeryAllergies:NKAMedication Intolerances:NonePEDIATRIC FILLABLE SOAP NOTE TEMPLATE2| P E D I A T R I C S O A P N O T E
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Family History .Mom has anemia. Oldest sibling has asthma. Father: Unknown Medical History Social History Patient is living with his mom, her boyfriend, and two siblings. Mom is cashier and graduated from high school. . His growth is slow he doesn’t say many words and doesn’t pick new things up very quickly. Mother and boyfriend smoke cigarettes in the home. He does not go to daycare. His mother’s boyfriend and neighbor watch him while mom is at work.Review of Systems (ROS)GeneralPatient looks listless, poor eye contact, lying still on exam table; CardiovascularMom denies chest pain, palpitations, PND, orthopnea, edema.SkinMom reports bruising in his abdomen after he had a fall from bed during a nap but denies bleeding or skin discolorations, itching, dryness, and any changes in lesions or moles.RespiratoryMom reports he is always congested but now breathing fast (may be due to nervousness) but denies cough, wheezing, hemoptysis, dyspnea, pneumonia. EyesMom denies blurring, diplopia, discharge, vision loss.GastrointestinalMom states he keeps rubbing his stomach all over and whines. He won’t eat anything, and he vomited once last night. Denies diarrhea, melena, and hematochezia.
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