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Nose/Mouth/Throat:Mother states he has had recent nose drainage but no bleeds, sinus congestion, post nasal drainage or reports of sore throat. Musculoskeletal: Denies any recent injury or fall. Denies any known deficits in age appropriate activities. Breast: deferredNeurological: Mother denies any complaints of headache. Has noted no gait abnormalities or recent Heme/Lymph/Endo: Mother denies any increase bruising or history of anemia. Mother denies any polyphagia or polydipsia. Weight appropriate for age. Fatigue at this time due to just not feeling good, she states. Psychiatry: Mother states no known history of depression and participates appropriately for age in all activities
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight: 12.5 kgTemp 102.0BP deferredHeight 78.74 cmPulse 134Resp 25OBJECTIVE: Physical Examination reveals a well-nourished female, well developed for age. Temp: 102.0, HR 134, RR 25, O2 sat 99% on room air. No blood pressure measured. Weight: 12.5 kgGeneral Appearance and parent-child interaction: Maternal/Child both appear well kept and are in clean clothing, interaction is normal, mother is very attentive to child needs.Skin General skin overview reveals no significant rash or other lesionHEENT Normocephalic, PERRL, Conjunctiva clear with no drainage noted. Tympanic membrane normal on right earand bulging on left ear, no exudation noted in right but left with exudation in ear canal, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted. Cardiovascular regular rate, capillary refill < 3sec. No gallop or murmur noted. Respiratory Breath sounds with expiratory wheezing bilaterally. Equal chest rise and fall.Gastrointestinal Bowel sounds heard in all four quadrants. Soft, no tenderness or distention noted upon palpation.
Patient negative for rebound tenderness. Negative for Murphy's sign, Rovsing's sign or tenderness at McBurney's point. Breast DeferredGenitourinary: No dysuria, urinary frequency, or urgency; No evidence of UTI, hematuria, pelvic pain, vaginal bleeding, vaginal discharge, no vulvar itching, pain or rash.Musculoskeletal: Musculoskeletal- Patient demonstrates full range of motion with no signs of pain. PEDIATRIC FILLABLE SOAP NOTE TEMPLATE Neurological Alert and appropriate for age. No signs of focal motor or sensory deficit.