“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 .
You've reached the end of your free preview.
Want to read all 9 pages?
- Summer '17
- Allergic rhinitis, Sinusitis, Mother/child