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Pediatric SOAP noteName: T.A.Date: 12/06/2019Sex: MaleAge/DOB/Place of Birth: 26 mo. oldSUBJECTIVEHistorian: Patient and her GrandmotherPresent Concerns/CC: Per patient’s Mother “Tommy had a minor fall from bed after his nap, since then he has been complaining of tummy ache, had one episode of vomiting, decreased appetite, and has had decreases peeing with dark foul-smelling urine.” Mom also states patient has been sweating and breathing hard.Child Profile: Sexual History: Deferred; ADL’s: Patient able to dress himself with assistance. Patient’s mother admits to poor dental hygiene. Safety Practices: Patient does not go to school, ride a bike or scooter, and always rides in a car seat. Patient does not play any sports. Developmental: Per mom patient walks and talks a little slower than children his age but is normally very appropriate. He is able to feed himself mostly, not yet fully potty trained, and exhibits slower than normal behavior and normal affect for his age. Patient is too weak to participate in exam.HPI: 26-month-old Caucasian male presents today with mother who states he had a minor fall and has been in distress since. Complains of abdominal pain, one episode of vomiting, no diarrhea, no fevers, patient is minimally responsive, tachycardic, tachypneic, diaphoretic, hypotensive, has old ligature marks noted to wrists, bruising noted to a distended abdomen, and is SIRS positive.Medications: NonePMH:Allergies: NKDAMedication Intolerances:NoneChronic Illnesses/Major traumas: Down’s Syndrome, ASD repair, Congestive Heart Failure-ResolvedHospitalizations/Surgeries: ASD repairImmunizations: Vaccines Up to Date per MotherFamily History:Father: UnknownMother:Living and HealthySocial History: occupational history: Denies exposurecurrent living situation: Lives with single Mother and siblingssubstance use/abuse: Denies exposureETOH, tobacco, and marijuana: Denies exposure Safety status: Denies exposure to any physical, psychological or sexual abuse, patient does exhibit signs of abuse, per mom child is “clumsy and falls a lot.”ROSGeneral: Denies fever, chills, denies weight loss or gain, admits to weakness and fatigue.Cardiovascular: Denies pedal edema, irregular heartbeat, low blood pressure, poor circulation, difficulty breathing on exertion, syncope or cold extremities.
Pediatric SOAP noteSkin: Denies any dry skin, lesions, redness or inflammation, tinea pedis, hives, scars, sores that won’t heal, masses, rashes, change in pigmentation, ulcers. Admits to bruises to abdomen, denies tinea corporis, hematomas, tinea cruris, toe-nail fungus.Respiratory: Denies shortness of breath, wheezing, hemoptysis,painful inspiration, coughEyes: Denies any itching, redness, discharge, cross eyes or cataracts.Gastrointestinal: Denies constipation, gastric reflux, rectal pain,bowel changes, hemorrhoids, flatulence, bloody stools. Admits to abdominal pain, admits nausea with one episode of vomiting, denies diarrhea, indigestion, fecal incontinence, black stools.