Answers all questions appropriately. Patient is alert and oriented to person, place, and time. Skin: Warm, dry, and intact. Capillary refill <3 seconds. Nails are smooth, color in correlation with patient, pink bed of nails. All 10 digits noted. No cracking, or cyanosis noted. No clubbing noted. Skin turgor elastic. No signs of dehydration noted. Hair is well distributed, blonde, and thick. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note Head: Head is normocephalic. Symmetrical. No lesions or masses noted. Scalp is intact, no lesions or nits noted. No craniofacial deformities noted. Hair is thick and soft, no signs of breakage noted . Eyes: PEERLA intact. EMO intact. Conjunctiva is pink, no drainage noted, no palpebral edema noted. Sclera is white, no drainage noted. Cornea intact. Eyelids pink, skin colored, no lessons or masses noted. Eyebrows are blonde in color, thick, and evenly distributed. Ears: Bilateral tympanic membranes are pearly grey with a good cone of light. Light reflex present. No perforations of tympanic membranes noted. Nose: There is no nasal drainage present. No pain upon palpation of sinuses. Septum is midline, no deviation noted. Nares are patent. Throat/Mouth: Oral mucosa is pink, intact, moist. No bleeding noted. Routine dental screenings performed every 6 months. Oral hygiene intact. No deformities or malformations noted on hard and soft palate. Deciduous teeth intact. Top upper left molar coming through. Posterior pharynx erythematous, no exudate noted. Tongue is midline. Tonsils are not enlarged and there is no exudate. Neck: Full range of motion noted. No stiffness or difficulties noted. Thyroid moveable, no enlargement noted. Trachea midline. Lymph noted palpable, no tenderness upon palpation. Cardiovascular: Rate and rhythm regular. No murmur or gallops noted. S1 and S2 noted. Pulses +2 bilaterally. PMI left 2 nd intercostal space, nondisplaced. No edema noted. Respiratory: Lungs clear. Regular rate and rhythm. Chest expansion equal and symmetrical. Work of breathing as ease. Gastrointestinal: Round, soft, non-distended. Bowel sounds presents LUQ, RUQ, LLQ, and RLQ. No hepatomegaly. Breast: No masses, lesions, tenderness, or discharged noted. No dimpling or discoloration of skin noted . Genitourinary: No CVA tenders. Tanner stage II. Musculoskeletal: ROM intact, no difficulties. Ambulates steady, no wobbling or leaning. Neurological: AAOx4. Calm. Cooperative. Spine midline, no difficulties with ROM. Posture erect.
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- Summer '17
- Physician, Sinusitis, neck pain, Flank pain