Respiratory: Nonlabored breathing, respirations regular rate and rhythm. Equal chest rises and fall. Breath sounds clear throughout with no adventitious breath sounds. Absent of wheezes, rales, rhonchi. No upper airway noise noted. Gastrointestinal: Umbilical stump healed with no drainage or odor noted. No abdominal distention noted. Abdomen soft and nontender with palpation. Bowel sounds active x all four quadrants. No hepatosplenomegaly noted on exam. Abnormal- 1 cm olive shaped mass-like are noted below xyphoid process to the right of epigastric areaBreast:Absence of swelling and nipple dischargeGenitourinary: newly circumcised penis healing without discharge or bleeding. Descended testes bilaterally. Musculoskeletal: Full ROM in all extremities, back/ spine straight, absence of edema. no hip clicks or clunks, appropriatestrength notedNeurological: Awake alert. Primitive gross motor reflexes moro, Babinski, flexor, and place reflexes noted. Primitive finemotor grasp reflex noted. Primitive rooting, sucking, and startle reflexes noted and observed. Cries when cold, laid out flat on table. Soothed when swaddled and cradled by mother. Behavioral/Psychiatric: Appropriate for age. No concerns at this time. Soothed when picked up by provider and/or mother. Appropriate mother/child bonding despite positive postpartum depression screening recorded by mother. Pediatric/Adolescent Assessment Tools: Postnatal Depression Screening- Total Score 19 (faxed to mothers OBGYN) counseling provided in office as wellPresent Developmental: Trust versus Mistrust Lab and/or Diagnostic Tests: abdominal ultrasound- positive for pyloric stenosis Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP NoteDIAGNOSISInstructions:1.Gastroesophageal reflux disease- K21. 9Reflux can be either noncomplicated or complicated in infants and children depending on the severity of symptoms. Noncomplicated GER involves a functional or physiological process in healthy infants and children without subjacent systemic anomalies. Symptoms can include daily regurgitation, mild respiratory issues such as nasal congestion, fussiness and/or crying for more than an hour a day, arching, and hiccups (Valeriu, Ancuta, Gabriela, & Marin, 2015). Noncomplicated GER usually disappears between the ages of six to twelve months of age. Complicated gastroesophageal reflux disease (GERD) is characterized by more than five episodes of regurgitations in one day, difficulty maintaining weight, persistent respiratory symptoms, and persistent irritability (Valeriu, Ancuta, Gabriela, & Marin, 2015). 2.Cow milk protein intolerance- Z91.011Cows milk allergy is the most common allergy among infants and children under four years of age, mostly infants. More prevalent in males than females, cows milk allergy is typically seen in the first few months of life after introduction of cow’s milk-based formula is introduced into one’s diet after exclusive breastfeeding is ceased. Symptoms often include feeding difficulties, vomiting, abdominal pain, dysphagia, failure to thrive, weight loss, and food impaction (Jarvinen-Seppo, 2019).
- Summer '17
- Vomiting, Pyloric stenosis