Younger sibling 3 month old female no known health problems Revised 5918 8918

Younger sibling 3 month old female no known health

This preview shows page 1 - 5 out of 9 pages.

Younger sibling (3 month old female)- no known health problems Revised 5/9/18; 8/9/18; 10/29/18
Image of page 1
Pediatric SOAP Note 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, younger sibling and grand parents. 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 car seat, unable to swim without floaties, 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 admits fever and decreased appetite. Reports fussiness for 5 days. Denies fatigue. 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 admit cough. Denies 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 Nose/Mouth/Throat: Mother/child reports clear/green nasal discharge. Denies sinus problems, sore throat, dysphagia, nose bleeds, 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 . Heme/Lymph/Endo: Mother/child denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Revised 5/9/18; 8/9/18; 10/29/18
Image of page 2
Pediatric SOAP Note Developmental Problems: Mother/child denies any developmental problems Behavioral Status/Psychiatric: Mother/child 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
Image of page 3
Pediatric SOAP Note OBJECTIVE ( Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives ) Weight: 35 lbs 15.9 kgs BMI 16.3 Temp: 102.1 BP: 98/62 Height: 34 in Pulse 98 Respirations: 22 General Appearance & parent child interaction:
Image of page 4
Image of page 5

You've reached the end of your free preview.

Want to read all 9 pages?

  • Summer '17
  • cough, Common cold, Upper respiratory tract infection, Mother/child

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes