Mother Alive Thyroid disease Asthma Social History Cu r r e n t li vi n g s it

Mother alive thyroid disease asthma social history cu

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Mother- Alive- Thyroid disease, Asthma 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 : The patient currently lives with her mother, father, 3 cats, and 2 dogs. E d uc a t io nal le v e l (as appropriate) : The patient is currently in 4 th grade. 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): Patient denies alcohol and substance abuse. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Firearms in home: Patient’s father denies firearms in house. S a f e ty s t a t u s : The home is protected without firearms. The patient states that she does not stay home alone for any period of time. The patient states that she knows to lock the doors, not talking to individuals that she doesn’t know, and lets her parents know everything that she is doing. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note REVIEW OF SYSTEMS (Do not omit any body system & remember this is a child not an adult) General: Reports increased fatigue over the past 2 days. Denies fever, difficulty sleeping, night sweats, unexplained weight gain/weight loss . Cardiovascular: Reports chest pressure when coughing. Denies chest pain. Denies swelling, palpitations. Skin: Denies eczema, itching, or dryness. Denies bruising easily. Denies hives, lumps, or moles. Respiratory: Reports shortness of breath and coughing. Denies asthma, bronchitis, coughing up blood. Denies productive sputum. Head: Denies dizziness, fainting, or head injury. Denies headache, pain, sweats, and swelling. Breast: Denies discharge, lumps, pain, and tenderness. Eyes: Denies blurred vision, discharged, double vision, and excessive tearing. Denies eyes pain, use of glasses, redness, or recent infection . Gastrointestinal: Reports occasional heartburn. Denies abdominal pain, constipation, diarrhea, changes in bowel movements. Denies change in appetite, excessive thirst, nausea, rectal pain, swallowing impairments, and vomiting. Ears: Denies discharge, dizziness, hearing impairments, infection, pain, ringing in ears, and excessive wax. Musculoskeletal: Denies joint pain, neck pain, and back problems. Denies deformities, joint stuffiness, muscle cramps, muscle stiffness, paralysis, weakness, and foot pain . Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Nose/Mouth/Throat: Reports congestion, discharge, and runny nose. Denies frequent colds, hay fever, infections, nasal obstruction, nose bleeds, and sinus infections . Neurological: Denies syncope, paralysis, and weakness. Genitourinary/Gynecological: Denies awakening to urinate and bed wetting. Denies blood in urine, burning, difficulties urinating. Denies flank pain, increase in frequency, incontinence, and pain. Denies starting a menstrual cycle. Denies lesions and itching. Heme/Lymph/Endo: Denies anxiety, sleeping difficulties. Patient denies suicidal ideation Developmental Problems: Patient and father deny developmental difficulties.
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  • Summer '17
  • cough, Common cold, nasal congestion

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