Child states my nose is stuffy and i sneeze after

“allergies”. Child states “my nose is stuffy and I sneeze after being outside a lot”. Mother states they do live near pecan trees which
she fears is the cause of the allergies. Denies any further complaints at present.
Medications :
No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for pain or fever.
Revised 5/9/18; 8/9/18; 10/29/18

Pediatric SOAP Note
PMH:
Allergies: NKDA
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries: None reported
Immunizations: Up-to-date
Family Medical History ( Identify all immediate family members, their age, & health status)
Mother: 27-year-old Hispanic female with no known health problems.
Father: 34-year- Hispanic male with no known health problems.
Older sibling (10 year old male)- no known health problems
Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Cu r r e n t li vi n g s it u a t io n / p-a r t n e r / m a r i t a l s t a t u s : Lives at home with mother, father, and older sibling.
E d uc a t io nal le v e l (as appropriate) : NA
O cc up a t i on a l h i s t o r y (as appropriate) : NA
S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): NA
Firearms in home: Father has guns which mother states is stored in a locked safe
S a f e ty s t a t u s : Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother states
sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
REVIEW OF SYSTEMS
(Do not omit any body system & remember this is a child not an adult)
General:
Mother/child denies fever and fatigue, decreased appetite.
Denies difficulty sleeping, chills, malaise, night sweats,
unexplained weight loss or weight gain.
Cardiovascular:
Mother/child denies chest pain, palpitations, PND, orthopnea,
edema
Skin:
Mother/child denies delayed healing, rashes, bruising,
bleeding or skin discolorations, any changes in lesions or
moles
Respiratory:
Mother/child denies cough, wheezing, hemoptysis, dyspnea,
pneumonia hx, TB
Head:
Mother/child denies headaches, concussions, unusual head
shape
Breast:
Mother/child denies lumps, bumps or changes
Eyes:
Mother/child denies corrective lenses, blurring, visual
changes of any kind
Gastrointestinal:
Mother/child denies abdominal pain, N/V/D. Denies
constipation, hepatitis, hemorrhoids, eating disorders, ulcers,
black tarry stools
Ears:
Mother/child denies ear pain, hearing loss, ringing in ears,
discharge
Musculoskeletal:
Mother/child denies back pain, joint swelling, stiffness or
pain, fracture hx, osteoporosis
Revised 5/9/18; 8/9/18; 10/29/18

Pediatric SOAP Note
Nose/Mouth/Throat:
Mother/child reports “stuffy nose” denies sinus problems,
sore throat, dysphagia, nose bleeds or discharge, dental
disease, hoarseness
Neurological:
Mother/child denies syncope, seizures, transient paralysis,
weakness, paresthesia, black out spells
Genitourinary/Gynecological:
Mother/child denies urgency, frequency burning, change in
color of urine .