PEDIATRIC SOAP NOTE Name: TA Date: 12/7/2019 Time: 0900 DOB/POB: 10/5/2017 Atlanta, GA Age: 26 months old Sex: M SUBJECTIVE Historian: Mother Chief Complaint: Abdominal pain, bruise on abdomen, not acting himself Child Profile: TA is a normally healthy, 26-month-old male with Down Syndrome. Pt mother reports child is current on vaccinations including annual flu vaccine. Pt mother reports child is normally happy and energetic. Pt mother states TA is shorter and underweight and is also developmentally behind because of the Down Syndrome. HPI: TA is a 26-month-old male patient who presents with his mother reporting abdominal pain that began 2 days. Pt mother states patient fell off his bed 2 days ago and began to c/o abdominal pain. Pt mother reports patient has a bruise on his abdomen, vomited once, hasn’t had a bowel movement in 1 day and has been breathing fast. Mother also reports decreased urine output with dark, odiferous urine. Pt mother denies treatment for symptoms. Parent states pain is worse when patient touches his abdomen. Mother also reports general malaise and loss of appetite. Medications: Denies. Past Medical History: Down Syndrome and Congestive Heart Failure. Allergies: NKDA Medication Intolerances: Denies Chronic Illnesses/ Major Traumas: Denies Hospitalizations/Surgeries: ASD repair
Family History: Mother: alive; Anemia. Father: unknown. Three siblings at home; healthy; one sibling as asthma. Social History: Patient currently lives with his single mother, mother’s boyfriend and three siblings. Mother denies exposure to cigarette smoke, drug use or alcohol use.
You've reached the end of your free preview.
Want to read all 5 pages?
- Summer '17
- NSG6435 Discussion