Pediatric SOAP Note Name: B.S. Date: 12/04/2019 Sex: Female Age/DOB/Place of Birth: 3 years, 6 months/05-04-2016/Valdosta, GA SUBJECTIVE Historian: Mother Present Concerns/CC : “We are here for our 3-year-old wellness exam, but she started not feeling good a couple of days ago. She is acting really tired and won’t eat hardly anything. She keeps telling me there is a sticker in her throat. Last night she ran a fever of 102 and this morning she had a fever of 102.6. Both fevers broke after I gave her Motrin. I would still like to see her growth development today if that’s possible.” Child Profile : B.S. performs all activities appropriate of her age. Mother states child can pedal her tricycle, draw on paper, and can speak more than 100 words. Mother also reports patient knows her shapes, can count to 20, and can sing her ABCs. Mother reports patient can run and jump and has no difficulty performing physical activity. She eats meats, fruits, and vegetables and drinks milk, water, and occasionally, apple juice. Mother states child rides in back seat with forward facing 5-point car seat. She is currently in her 2 nd year of day-care and is at home with mother and father after day- care hours and on weekends. Mother reports child is very social with other children and plays well with other children. HPI: B.S. is a 3-year-old Caucasian female presenting to the clinic today with her mother. She was originally schedule for her 3-year-old wellness exam but has recently became ill. Mother reports B.S. has had diminished appetite x2 days and high-grade fever x18 hours. Mother also claims that child has been stating she has a “sticker” in her throat x2 days. Patient is unable to rate throat pain using Wong-Baker FACES Scale. Associated symptoms include lethargy and loss of appetite. There are no aggravating or alleviating factors. Medication tried includes OTC Motrin, in which mother states has brought fever down and made patient less fussy. She has no pertinent medical or surgical history pertaining to today’s visit. Medications : OTC Motrin (100mg/5ml) 5ml PO q6hrs PRN for fever/pain PMH: 2/6 Murmur- Ventricular Septal Defect Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None Immunizations: Up to date on all childhood vaccinations per age appropriate Family History Mother- (T.S. 26-year-old): No significant medical history Father- (K.S. 28-year-old): Seizures as an infant- unsure of cause Brother- (P.S. 8-year-old): No significant medical history Social History B.S. currently resides with her father, mother, and brother in a home built in 2009. She attends a local private in- home daycare where mother claims that education is taught very well. Her mother states B.S.’s hobbies are playing outside, playing with her friends at daycare, and playing with her dog. Mother reports no one in the home drinks alcohol, smokes nicotine, or participates in recreational street drug use. Both sets of grandparents are greatly involved in child’s care.
Pediatric SOAP Note ROS General
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