Denies diarrhea, constipation, hepatitis, hemorrhoids, ulcers, black tarry stools. Refusing to eat or drink. Ears Denies ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Decreased urine output, dark urine, and odor to urine. Nose/Mouth/Sinus/Throat problems Denies dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain. Musculoskeletal Denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast Deferred Neurological Denies syncope, seizures, transient paralysis/ Does have weakness. Heme/Lymph/Endo Denies HIV status, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance. Has bruising to abdomen. Psychiatric Has been having sleeping difficulties, waking up whining and irritable. 3 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight 10 kg Temp 97.9 oral BP 68/40 Height 71cm Pulse 160 Resp 50 OBJECTIVE (Physical Examination) General Appearance and parent-child interaction Listless male with downs syndrome. Has pale, cool, clammy skin. He is lying still and not making eye contact. He is breathing rapidly in moderate distress. Skin Skin is pale, cool. And clammy. Ecchymosis to epigastric area 10cm in length. Has diffuse rash to perineum. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth have noticeable dental caries. . Cardiovascular S1, S2 with regular rate and rhythm and systolic murmur. Previous AV septal defect repair. Respiratory Symmetric chest wall. Respirations regular, shallow, and rapid at 50-60 breaths per minute. Oxygen saturation at 93% on room air. Gastrointestinal Abdomen distended, firm, and bruising noted to epigastric. BS active in all 4 quadrants. Breast Deferred Genitourinary Bladder is non-distended; Both testes palpable, no masses or lesions, no hernia, no uretheral discharge 4 | P E D I A T R I C S O A P N O T E
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE Musculoskeletal Flaccid Neurological Not making eye contact.
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- Summer '17
- tommy, NSG6435 Week 7 Discussion