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Pediatric SOAP NoteNP Student Name: Sarah TolerChild’s Initials: EBDOB: 2.16.2016Clinical Date: 11.20.2020Age: 3 years 9 months Place of Born: Dublin, Ga Week Soap Project: Week 4Sex: F ___Type of Soap Note:Sick visit ____SUBJECTIVEHistorian: Mother Present Concerns/CC: Fever and cough x 2 days. Flu positive last week. Child Profile:Activities of Daily Living(ageappropriate): patient sleeps in her own bed in shared room with sister. Helps with getting herself dressed. Very independent. Feeds self. Regular diet. Toilet trained days and night. Patient knows how to self-administer epi pen in case of emergencies due to severe food allergies from very young age. SafetyPractices: 4-point carseat in back seat. Allergy action plan provided for all childcare providers. Epi pen carried by parents as well as childcare providers. Smoke alarms in home. Child safety locks utilized in bathroom and kitchen. Changesindaycare/school/after-schoolcare: In home daycare with brother and 5 other children in home. Sports/physicalactivity: N/ADevelopmentalHistory: Developmental screening appropriate for age. Able to pedal tricycle, toilet trained, knows colors, counts to 20, knows alphabet, knows shapes, follows 3 step commands, SexualHistory(ifappropriate): N/AHPI: Patient had positive flu last week. Fever resolved and started back 2 days ago. Mother reports cough, sore throat, decrease urinary output and decreased appetite. Medications: Singulair 5 mg PO QHS- asthma PMH:Allergies: Undergone allergy testing multiple times Eggs- unknownPeanuts- anaphylaxis Pear- unknownPork derived- UnknownAmoxicillin- Rash/ HivesAugmentin- Rash/HivesSulfamethoxazole (from Bactrim)- RashTrimethoprim (From Bactrim) – RashChronic Illnesses/Major traumas: Multiple food allergiesH. PyloriAnemia Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP NoteHospitalizations/Surgeries:PE tubes 4/11/2017Immunizations: Up to Date per GRITS immunization system, no flu shotFamily Medical History Paternal grandfather- HTNSocial History Currentlivingsituation/partner/maritalstatus: Lives with mom, dad, 8-year-old sister, 2-year-old brother Educationallevel (as appropriate): Will start Pre-k upcoming school year Occupationalhistory (as appropriate): N/ASubstanceuse/abuse(ETOH, tobacco, and marijuana): Secondhand smoke exposure at homeFirearms in home: All firearms in locked gun safe with keep kept in different location Safetystatus: No safety concerns at this time REVIEW OF SYSTEMS(Do not omit any body system & remember this is a child not an adult) General: Mother reports fever and poor appetite Cardiovascular: Mother denies heart related issues to include palpitations, edemaSkin: Mother denies rashes, skin changes, lesions, change in temperature Respiratory: Mother reports cough, audible wheezing (worseat night).