Nose/Mouth/Throat : Mother denies nasal discharge, denies drooling, bleeding gums, or nasal obstructions. She complains of a sore throat that has appeared 2 days after fever. Musculoskeletal: Mother denies history of broken bones, no muscle or joint pain. Breast: Mother reports no changes in breast, denies masses or lumps. Neurological: Mother denies syncope, seizures, transient paralysis, weakness, paresthesia’s, black out spells. No tics or tremors, headaches or black out spells. Heme/Lymph/Endo: Mother denies history or anemia, no blood transfusions or bleeding disorders. No growth problems. No endocrine disorders. OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth Weight 55 lbs BMI: 16 Temp 101.5 DegF BP 110/72mmhg Height 125 cm Pulse 84 b/m Resp 25
Pediatric SOAP Note
Pediatric SOAP Note General Appearance Healthy appearing female is currently ill appearing. She coughs often. Sitting on chair. Developmental age seems to be in conjunction with stated age. She is clean and dressed well, appears well nourished. Appropriate weight and febrile currently. Skin Skin is light in color, warm to touch, dry, clean and intact. No rashes or lesions noted. Hair is blonde and evenly distributed on her head, it is clean and pulled back in a ponytail. HEENT : Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Non-tender, no masses lumps, rashes or scales noted. Eyes: No redness, PERRLA. 3mm, external auditory canal intact. No conjunctival or scleral infection. Ears: Ear Canals patent. Bilateral tympanic membrane pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink and inflamed, normal turbinate. No nasal septal deviation, sinus pressure present. Neck: Full ROM, no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is non- erythematous and without exudate. Patient complains of sore Cardiovascular Normal palpation of heart: PMI nondisplaced; auscultation of heart: regular rate & rhythm. No murmurs heard, Peripheral pulses are strong. No edema noted, brisk capillary refill in all extremities
Pediatric SOAP Note Respiratory Normal respiratory effort, no retractions, no tachypnea, auscultation of lungs presents with rhonchi with rales. No wheezing present. Cough present with yellowish mucoid sputum. Symmetric chest walls. Respirations regular and rapid. Gastrointestinal: Abdomen: soft, nontender/nondistended, and no mass, no rigidity/rebound or guarding. Normal liver & spleen: no hepatosplenomegaly. Abdomen flat, bowel sounds active in all 4 quadrants. Abdomen soft, non-tender. Abdomen: soft, nontender/nondistended, with increased hyperactive bowel sounds and no mass, no rigidity/rebound or guarding. Normal liver & spleen: no hepatosplenomegaly.
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- Summer '17
- productive cough