SU_NSG6435_W4CORE_SOAP_TOLER_S.docx - Pediatric SOAP Note NP Student Name Sarah Toler Child\u2019s Initials EB DOB 2.16.2016 Clinical Date 11.20.2020 Age 3

SU_NSG6435_W4CORE_SOAP_TOLER_S.docx - Pediatric SOAP Note...

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Pediatric SOAP Note NP Student Name: Sarah Toler Child’s Initials: EB DOB: 2.16.2016 Clinical Date: 11.20.2020 Age: 3 years 9 months Place of Born: Dublin, Ga Week Soap Project: Week 4 Sex: F ___ Type of Soap Note: Sick visit ____ SUBJECTIVE Historian: Mother Present Concerns/CC: Fever and cough x 2 days. Flu positive last week. Child Profile: Activities of Daily Living ( a g e a pp r o p r i at e) : 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. S a f e ty Pr act i c e s : 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. C h a n ge s i n d a y ca r e / s c h ool /a f t e r-s c h oo l ca r e : In home daycare with brother and 5 other children in home. S p o r t s / ph y s ical ac t i vi t y : N/A D e v elo p m e n tal History : Developmental screening appropriate for age. Able to pedal tricycle, toilet trained, knows colors, counts to 20, knows alphabet, knows shapes, follows 3 step commands, S ex u al H i s t o r y (i f a p p r o p r i at e ) : N/A HPI: 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- unknown Peanuts- anaphylaxis Pear- unknown Pork derived- Unknown Amoxicillin- Rash/ Hives Augmentin- Rash/Hives Sulfamethoxazole (from Bactrim)- Rash Trimethoprim (From Bactrim) – Rash Chronic Illnesses/Major traumas: Multiple food allergies H. Pylori Anemia Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Hospitalizations/Surgeries: PE tubes 4/11/2017 Immunizations: Up to Date per GRITS immunization system, no flu shot Family Medical History Paternal grandfather- HTN Social History Cu r r e n t li vi n g s it u a t io n / pa r t n e r / m a r i t a l s t a t u s : Lives with mom, dad, 8-year-old sister, 2-year-old brother E d uc a t io nal le v e l (as appropriate) : Will start Pre-k upcoming school year O cc up a t i on a l h i s t o r y (as appropriate) : N/A S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): Secondhand smoke exposure at home Firearms in home: All firearms in locked gun safe with keep kept in different location S a f e ty s t a t u s : 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, edema Skin: Mother denies rashes, skin changes, lesions, change in temperature Respiratory: Mother reports cough, audible wheezing (worse at night).
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  • Summer '17
  • cough, Common cold

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