PMH: Allergies: NKDA Revised 5/9/18; 8/9/18; 10/29/18

Pediatric SOAP Note 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: 39-year-old white female with diabetes; II. Father: 42-year-old white male with high hypertension 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 are stored in a locked safe S a f e ty s t a t u s : Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seatmother 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 reports fever and fatigue. Mother denies decreased appetite. Denies difficulty sleeping, chills, malaise, night sweats, unexplained weight loss or weight gain. Cardiovascular: Mother denies chest pain, palpitations, PND, orthopnea, edema Skin: Mother denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory: Mother denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Head: Mother denies headaches, concussions, unusual head shape Breast: Mother denies lumps, bumps or changes Eyes: Mother denies corrective lenses, blurring, visual changes of any kind Gastrointestinal: Mother reports vomiting x 2. Mother denies abdominal pain, Diarrhea. Denies constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears: Mother denies ear pain, hearing loss, ringing in ears, discharge Musculoskeletal: Mother denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Mother reports sore throat and swollen tonsils. Mother denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness Neurological: Mother denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells Revised 5/9/18; 8/9/18; 10/29/18

Pediatric SOAP Note Genitourinary/Gynecological: Mother denies urgency, frequency burning, change in color of urine . Heme/Lymph/Endo: Mother denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Developmental Problems: Mother denies any developmental problems Behavioral Status/Psychiatric: Mother denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Revised 5/9/18; 8/9/18; 10/29/18