Cardiovascular Mother denies any cardiovascular issues like edema heart

Cardiovascular mother denies any cardiovascular

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Cardiovascular Mother denies any cardiovascular issues like edema, heart palpitations, chest pain. Skin Mother reports no skin issues such as rashes, lesions or moles. Respiratory Mom reports no recent respiratory infections, coughing, SOB or snoring at night. Eyes Mother denies redness, eye pain, noticeable squinting or blurry vision Gastrointestinal Mother denies vomiting, nausea, constipation, diarrhea or blood in stool. Mom reports patient is 90% potty trained-still using diapers at night. Ears Mom denies any excess ear discharge, past ear infections or hearing difficulties. Genitourinary/Gynecological Mom 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/Throat Mom denies snoring, sore throat, or nasal congestion. Musculoskeletal Mom denies muscle aches or difficulty with moving around. Breast Mother reports no changes in breast. Neurological Mother reports no past history of seizures, headaches or syncope. Heme/Lymph/Endo Mother denies growth issues, hot/cold intolerances or history of needing a blood transfution Psychiatric Mother denies mood changes, any sign of anxiety or depression. We ight 32lb 5oz BMI: 15.7 T 97.9 F B P 72/44 H e ight 38 in HR 119 R 28 P ediat r ic SOAP N o te
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P ediat r ic SOAP N o te
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General Appearance Pt 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. Skin Skin is intact, dry and clean. No sores, bruises or lesions noted. HEENT Normocephalic, patient has blonde hair that is evenly distributed and clean. Pupils equal, round, and reactive to light and accommodation Tympanic membranes pearly grey and intact, no ear drainage noted bilaterally, Nasal passages clear.
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  • Summer '17
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