Review of Systems (ROS) Eyes: No drainage from eyes. Denies any pain or itching to bilateral eyes. Patient does not use eye glasses. General: Mother states normally healthy; recent cough, congestion and fever; immunizations are current; normal sleep patterns; no history of congenital syndromes or chromosomal abnormalities Cardiovascular: Mother denies any unusual shortness of breath with age appropriate activities. No recent complaints of chest pain Skin: Mother denies any recent skin complaints including rashes, abnormal moles, dry skin, or irritation. Respiratory: No cough or increased work of breathing. symmetric chest expansion; clear breath sounds. Gastrointestinal: Negative for abdominal pain and nausea/vomiting. Mother denies any appetite loss, denies any known constipation, diarrhea, flatulence, heartburn. Last stated bowel movement was this Ears: No history of recurrent otitis media; no evidence of tympanic membrane perforation; no evidence of otitis externa, cholesteatoma, otorrhea, otalgia, and mastoiditis; no ear deformities noted, no history of a foreign body in the ear; no signs of hearing loss Genitourinary/Gynecological: Denies any known discharge. States she has been urinating normal, no difficulties. Nose/Mouth/Throat: Denies drainage but no bleeds, sinus congestion, post nasal drainage or reports of sore throat. Musculoskeletal: Denies any recent injury or fall. Denies any known deficits in age appropriate activities.
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight: 34.47 kg Temp 98.4 BP 98/62 Height 124.46 cm Pulse 82 Resp 22 OBJECTIVE: Physical Examination reveals a well-nourished male, well developed for age. Temp: 98.4 HR 82, RR 22, O2 and blood pressure 98/62 Weight: 34.47kg, height 124.46 cm. Normal neurological exam performed in the office, no signs or symptoms of seizures. Child does not fall over during the episodes nor does he remember them.
- Summer '17
- Grandparent, Attention-deficit hyperactivity disorder