Home is childproofed with covers on electrical outlets sits in the backseat

Home is childproofed with covers on electrical

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Home is childproofed with covers on electrical outlets, sits in the backseat with seat belt and swims without floatation devices, mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure REVIEW OF SYSTEMS (Do not omit any body system & remember this is a child not an adult) General: Mother/child admits fever, malaise and decreased appetite for 7 days. Denies fatigue. Denies difficulty sleeping, chills, night sweats, unexplained weight loss or weight gain. Cardiovascular: Mother/child denies chest pain, palpitations, PND, orthopnea, edema Skin: Mother/child denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory: Mother/child admit cough. Denies wheezing, hemoptysis, dyspnea, pneumonia hx, TB Head: Mother/child denies headaches, concussions, unusual head shape Breast: Mother/child denies lumps, bumps or changes Eyes: Mother/child denies corrective lenses, blurring, visual changes of any kind Gastrointestinal: Mother/child admits vomiting. denies abdominal pain, diarrhea. Denies constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears: Mother/child denies ear pain, hearing loss, ringing in ears, discharge Musculoskeletal: Mother/child denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Nose/Mouth/Throat: Mother/child reports clear nasal discharge, sinus problems, sore throat, nasal congestion. Denies dysphagia, nose bleeds, dental disease, hoarseness Neurological: Mother/child denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells Genitourinary/Gynecological: Mother/child denies urgency, frequency burning, change in color of urine . 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 Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note 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: 132 lbs 59.4 kgs BMI 24.1 Temp: 99.5 BP: 76/46 Height: 52 in Pulse 105 Respirations: 22 General Appearance & parent child interaction: Well-nourished, developmentally appropriate, alert, healthy and active appearing female child, in no acute distress. Pale complexion Skin: C olor appropriate 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; brown/black, thick, silky, straight; hair clean and shiny; 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 brown/black, thick, silky, straight; hair clean and shiny; no nits or scalp lesions seen.
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  • Summer '17
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