HemeLymphEndo Motherchild denies depression anxiety sleeping difficulties

Hemelymphendo motherchild denies depression anxiety

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Heme/Lymph/Endo: Mother/child denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Developmental Problems: Mother/child denies any developmental problems Behavioral Status/Psychiatric: Mother/child denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note OBJECTIVE ( Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives ) Weight: 41.lbs 18.6kgs BMI 16.3 Temp: 98.4 BP: 98/62 Height: 42in Pulse 98 Respirations: 22 General Appearance & parent child interaction: Well-nourished, developmentally appropriate, alert, healthy and active appearing female child, in no acute distress; Child interacting appropriately with parent and office staff. Skin: C olor brown without evidence of cyanosis, jaundice, or pallor; pigmentation even; no nevi; skin warm, smooth, and dry with elastic turgor; no evidence of edema; no bruising, rashes, or lesions noted Hair: hair well distributed; black, thick, silky, straight; hair clean and shiny pulled back in a ponytail; no nits or scalp lesions seen Nails: nails present on all 10 digits, nail beds pink, not brittle; no evidence of clubbing or other deformities; capillary refill < 2 seconds Head: Head is normocephalic; No craniofacial abnormalities; symmetrical, no masses or lesions, hair black, thick, silky, straight; hair clean and shiny pulled back in a ponytail; no nits or scalp lesions seen Eyes: PERRLA; EOM intact; Conjunctiva are clear and pale without palpebral edema. eyeballs are in the same plane as eyebrow and maxilla. Lids symmetrical. Vision 20/20 bilateral eyes. Ears: Ear canals are patent bilaterally with mild cerumen; pearly gray TMs, non-bulging in appearance bilaterally Nose: nose smooth, symmetrical alignment; no deviation or lesions; septum midline without deviation; nares patent bilaterally; turbinates mildly erythematous bilaterally with small amount of clear drainage noted bilaterally. Throat/Mouth: Oral mucosa is pink, moist, and intact with gingival tissue pink without bleeding. Optimal oral hygiene noted without dental debris; Deciduous teeth all intact, hard and soft palate are without obvious malformation or trauma; Posterior pharynx is clear in appearance; appropriate amount of saliva noted to ensure adequate hydration Neck: Soft, supple, without palpable lymphadenopathy; No protrusions or areas of tenderness upon palpation; no nuchal rigidity noted Cardiovascular: Regular rate and rhythm without murmur, rub or gallop; peripheral and central pulses are palpable at 2+, without any edema; PMI nondisplaced Respiratory: Lung sounds clear bilaterally in all lobes with regular, unlabored respiratory rate; No adventitious sounds noted upon auscultation Gastrointestinal: soft, and non-distended; no tenderness upon palpation; normo-active bowel sounds in all four abdominal quadrants; Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note Breast:
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