STUDENT NAME: Eva JonesPatient Initials: TADate of Encounter: 12/5/2019Sex: MAge/DOB: 26 MPlace of Birth: ihumanSUBJECTIVEHistorian: MotherPresentConcerns/CC: Patient comes into ED with mother who reports a fall from bed and abdominal pain for two days.Child Profile: Child within the toddler stage, currently appearing listless and drowsy. Vocabulary is limited. Patient has developmental disability; Down Syndrome. HPI: Patient is 26 month old who presents to the ED with mother/caregiver with complaints of abdominal pain for two days with vomiting once. The mother reports he had fallen out of bed after his nap. She denies any head trauma or any past history of trauma. Per mother, patient has not been eating or drinking with decreased urine output, breathing faster, and lethargic. He has had no change in bowel habits. Patient has a history of down syndrome and atrial-septal defect with surgical repair and symptomatic CHF that has resolved after surgery. Medications: None.PMH: Down Syndrome.Systolic Murmur.Heart Failure.Atrial-Septal defect with surgical repair.Allergies: NKDAMedication Intolerances: NoneChronic Illnesses/Major traumas: Denies.Hospitalizations/Surgeries: Atrial-Septal Defect Repair. Immunizations: Reportedly up to date per mother.PEDIATRIC FILLABLE SOAP NOTE TEMPLATE1| P E D I AT R I C SO AP N O T E
Family History Lives with mother only, three children at home.Social History Parents: Mother, single with three children at home. No Day care. Water: city. Exposure to second hand smoke, mother smokes and so does boyfriend at home. No Pets at home: Home heat type: forced air. No signs of mold/mildew in home. No international.Review of Systems (ROS)GeneralListless, Dehydrated. Decreased level of responsiveness.CardiovascularDenies cyanosis.Admits Rapid breathingSkinScar on chest. No scratches. Bruise on abdomen.RespiratoryDenies wheezing, hemoptysis, dyspnea, or TB exposure.Reports slight congestion and cough without sputum.EyesDenies noticing any vision changes and difficulty seeingobjects.GastrointestinalDenies constipation. Patient has vomited. EarsDenies signs of ear pain, hearing loss, or any discharge.Genitourinary/GynecologicalDenies signs of frequency, burning,. Decreased urine output with darker color change.
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