Cardiovascular mother denies any cardiovascular

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

P ediat r ic SOAP N o te

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.