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CardiovascularMother denies any cardiovascular issues like edema, heart palpitations, chest pain. SkinMother reports no skin issues such as rashes, lesions or moles. RespiratoryMom reports no recent respiratory infections, coughing, SOB or snoring at night.EyesMother denies redness, eye pain, noticeable squinting or blurry vision GastrointestinalMother denies vomiting, nausea, constipation, diarrhea or blood in stool. Mom reports patient is 90% potty trained-still using diapers at night. EarsMom denies any excess ear discharge, past ear infections or hearing difficulties. Genitourinary/GynecologicalMom reports no change in urine color, burning or frequency. Pt does wear diapers (pull ups) at night but is otherwise using the toilet. Nose/Mouth/ThroatMom denies snoring, sore throat, or nasal congestion. MusculoskeletalMom denies muscle aches or difficulty with moving around.BreastMother reports no changes in breast. NeurologicalMother reports no past history of seizures, headaches or syncope. Heme/Lymph/EndoMother denies growth issues, hot/cold intolerances or history of needing a blood transfution PsychiatricMother denies mood changes, any sign of anxiety or depression. Weight 32lb 5ozBMI: 15.7T97.9 FBP 72/44Height 38 inHR119R28PediatricSOAPNote
General AppearancePt is sitting with her Mom, holding her stuffed animal, in no distress. Pt appears to be clean and well nourished. Mother and child appear to have a great relationship. Pt’s stated age seems to correlate with developmental age. SkinSkin is intact, dry and clean. No sores, bruises or lesions noted. HEENTNormocephalic, patient has blonde hair that is evenly distributed and clean. Pupils equal, round, and reactive to light and accommodationTympanic membranes pearly grey and intact, no ear drainage noted bilaterally, Nasal passages clear.