Name: K.P. Date: 1/27/20 Sex: Female 5 years, 10/13/2014, Place of birth: S.C. SUBJECTIVE Historian: Mother Kim Present Concern / CC: “ Sore throat, productive cough, fever and fatigue.” “Well child visit” Child Profile: 5-year-old child presented in clinic today with ill looking appearance. Mother Kim says that her child was not feeling well for the past four days. The mother complaints of fever, sore throat, productive cough and fatigue that her child is experiencing. She guesses the child might have some type of infection. HPI: Mother Kim states “my daughter has been ill for past 4 days. She has fever, sore throat and productive cough.” K.P. is very tired and could not go to school. The patient has no previous medical history requiring treatment or chronic care. The child looks tired and ill but looks well nourished and well groomed. She is alert and oriented and responds to questions when asked. Medications : Ibuprofen 200mg for fever the past 2 days. PMH: K.P. was a planned pregnancy with prenatal care beginning at approximately 12 weeks gestation. Mom was healthy during pregnancy, she did not smoke, consume alcohol or illegal drugs. She reports no illness during pregnancy. The only medications she took was a daily prenatal and folic acid. She had a 29-pound weight gain during pregnancy, delivered vaginally with no complications. Child is healthy with no reported illnesses or infectious diseases. Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: No surgical history or hospitalizations reported. Immunizations: Previous records shows all immunizations are up to date. Pediatric SOAP Note
Family History Mother – Living Healthy Father – Living Healthy Social History K.P. is currently living with her parents (father and mother) in a house. KP is in preschool and goes regularly. She likes to interact with children of her age. She participates in activities, plays hopscotch, tag and does swimming classes weekly on Thursday. She is doing well in preschool. Mom denies alcohol or substance use by her or child’s father. ROS General: Mother reports the child is very ill now, she feels tired all the time. She consumes healthy diet daily and drinks water. Mom weight changes, recent illness, sleep issues, or difficulty performing ADLs. Cardiovascular: Mother denies any previous heart conditions, no chest pain, no palpitations, no dizziness, no chest pressure, no blue or cold fingers. Skin: Mother denies a history of birth marks, skin lesions, no rashes, no issues with fingernail or hair growth. Skin is warm to touch due to fever. Skin is dry and healthy. Respiratory: Mother denies any SOB, frequent respiratory infections, blue spells, snoring at night or sleep apnea.
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