SU_NSG6435_W7_A1_SWANSON_TIFFANY(vincent 6453 w7 d1).docx - PEDIATRIC FILLABLE SOAP NOTE TEMPLATE STUDENT NAME Tiffany Swanson Patient Initials TA DATE

SU_NSG6435_W7_A1_SWANSON_TIFFANY(vincent 6453 w7 d1).docx -...

This preview shows page 1 - 4 out of 16 pages.

STUDENT NAME: Tiffany SwansonDATE OF ASSIGNMENT: 12/02/2019Patient Initials:TADate of Encounter: 10/05/2015Sex:MaleAge/DOB/Place of Birth:Unknown place of birth8/5/2013- 26 monthsSUBJECTIVEHistorian: MOMPresent Concerns/CC:"He isn’t himself. He is been whining a lot and refusing to eat. He has been rubbing his tummy” Child Profile:26-month-old Caucasian male with downs syndrome. Mom states “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 to 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 of his 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 distended with a large bruise approximately 10cm in the lower portion.O-2 days agoL-AbdomenD-ConstantC-Unable to assess characteristicsA 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
Background image
Medications: (List with reason for meds)None PMH:Born with Downs syndromeCHFCardiac 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
Background image
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 a 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.
Background image
Image of page 4

You've reached the end of your free preview.

Want to read all 16 pages?

  • Summer '17
  • NSG6435 Discussion

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes