SU_NSG6435_W2SOAP_Andre_T.docx - Pediatric SOAP Note Name B.M Date Sex Female Age\/DOB\/Place of Birth 4 Years East GA Regional Medical Center Statesboro

SU_NSG6435_W2SOAP_Andre_T.docx - Pediatric SOAP Note Name...

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Name: B.M. Date: 09-12-2019 Sex: Female Age/DOB/Place of Birth: 4 Years / 07-11-2015 / East GA Regional Medical Center; Statesboro, GA SUBJECTIVE Historian: Caregiver/Birth Mother as historian Present Concerns/CC : “Every time she pees, she complains about her crotch burning. It happened once to twice about a week ago; I put some cream on it and she didn’t fuss again until yesterday. That’s when she told me her burning was back; I also noticed she’s sitting on the toilet a good bit longer than usual. Also, when she does go it’s because she’s waited until she can’t hold it any longer and she’s wet her panties a few times at school from holding it; otherwise, she’s not complained about anything and I don’t see anything else abnormal.” Child Profile :( Sexual History(if appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) B.M. wears a helmet to ride her bike, without training wheels; and is able to maintain steady balance. B.M. is able to skip, jump, and hop on either foot. She correctly recognizes and identifies all of her colors, most letters, and many shapes. She is able to write her name; and speak in complete sentences. She successfully integrated socially at school and enjoys recess where she plays well with classmates. B.M. spends non-school hours with her “PaPaw” until Mom or Dad pick her up after work. HPI: (must include all components) B.M. is a well-appearing, jovial 4-year-old Hispanic female in today by her Mother who asserts B.M. c/o her “crotch area burning when she goes to the bathroom;” since yesterday with the initial occurrence beginning last week that was resolved by topical cream application. Her mother reports once B.M. reported the burning sensation she also “noticed she was sitting on the toilet longer than usual.” She does admit the patient has occasional accidents and has remained in soiled panties at school. She denies fever/chills/nightsweats; denies additional symptoms. Mother also denies dietary changes; denies caffeine consumption; and she denies changes in bath soaps or laundry detergent. Medications : (List with reason for med) NONE reported PMH: No reported significant past medical history. Allergies : NKDA Medication Intolerances : NONE ChronicIllnesses/MajorTraumas : NONE Hospitalizations/Surgeries : None Immunizations : UTD Family History ( Please identify all immediate family) B.M’s parents are currently living and are in good medical standing. Her 13-month-old sister is also in good medical standing. Her maternal Grandmother has a history of HTN and T2DM, which are regulated with medication and diet. Her maternal grandfather has a cardiac history which is well controlled now. Her paternal grandparents are currently living and in
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