Heme/Lymph/Endo: Complaints of abdominal bruising. Denies fever. Denies lymph node tenderness or swelling. Denies history of thyroid disease, anemia or diabetes. Developmental Problems: Developmental delayed related to diagnosis of Down Syndrome. Behavioral Status/Psychiatric: Complaints of poor sleep, increased whining x 2 days. Denies depression or suicidal ideations.
Pediatric SOAP Note tender. No evidence of inguinal herniation. Normal size, shape and consistency (rubbery) prostate. No nodules or tenderness noted. No visible fissures, induration or lesions of rectum. Stool brown, heme-negative. Musculoskeletal: Full ROM seen in 4 extremities. Normal bulk, no rigidity or signs of trauma. Non-tender to vertebral palpation, and no overt back deformities. Non-tender to percussion of back and spine. No scoliosis noted. Neurological: Bicep reflex, triceps reflex, brachioradialis reflex, patellar reflex, and Achilles reflex are all intact bilaterally and within normal limits. CN II-XII intact. Pt is alert to verbal stimulation and pain stimulation. Behavioral/Psychiatric: Alert to stimuli. Patient has poor eye contact, listless, lethargy. Increased whining, patient has delayed response. Pediatric/Adolescent Assessment Tools: (Ages & Stages, etc.; HEADSS Assessment for adolescents; include results and rationale; ) Communication: 1. Delayed related to Down Syndrome diagnosis 2. Babbles words 3. Responds to familiar words 4. Shows needs by gesture Gross motor: 1. Sits alone 2. Crawls 3. Stands 4. Walks alone 5. Trips and falls often Fine Motor: 1. Follows objects with eyes 2. Reaches out and grasps object 3. Passes objects from hand to hand 4. Builds a tower of two cubes Problem Solving 1. Plays with age appropriate toys Personal-Social 1. Finger feeds 2. Drinks from cup unassisted 3. Uses spoon (Burns, Dunn, Brady, Starr, & Blosser, 2016) Present Developmental: Patient developmentally delayed for milestones due to diagnosis of Down Syndrome. Lab and/or Diagnostic Tests: (include results or pending) Head CT: normal Comprehensive metabolic panel (CMP): abnormal Urinalysis (UA): abnormal Complete blood count (CBC): abnormal PT/INR: abnormal Skeletal survey: abnormal- acute rib fracture left 8 th ; healing rib fractures, right 4 th and 5 th ; old rib fractures, right 9 th and 10 th ; NG tube tube and foley catheter in place; diffuse bowel distention. Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Note Venous blood glasses (VBG): abnormal Lipase: abnormal Amylase, serum: abnormal elevation Lactic acid, serum: abnormal CT abdomen/pelvis with IV contrast: abnormal Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Note DIAGNOSIS Instructions: 1. Traumatic intra-abdominal organ injury (S36.899A)- injury to the abdomen that can have symptoms of abdominal pain, bruising of external abdomen. It can be contributed by plunt force or penetrating and involve damage to abdominal organs (Burns et al., 2016).
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- Summer '17
- Burns, Penetrating trauma, blunt trauma