Pediatric SOAP Note
| Name: A.P | Date: 04/27/2018 | |
| Sex: Male | Age/DOB/Place of Birth: 2 Y.O/ 04/18/2016/ Hialeah, FL | |
| SUBJECTIVE | ||
| Historian: Patient and motherPresent Concerns/CC: “We are here for follow up on labs results after frequent episodes of nose bleeds” | ||
| Child Profile:Patient is a 2 years old toddler who lives with both parents and grandmother from his mother side. He attends daycare Monday –Friday from 8-5 and the rest of the time is cared at home by his parents and grandmother. He drinks 8 ounces of whole milk x 3 times daily and eats solid foods. He is described as a good eater, and his diet include rice, beans, meat and yogurt. He does not like vegetables or fruits but parents try to include them. Patient has met all his milestones on time. He knows most colors, speaks 4-5 words sentences and is able to count to 12. Patient is in the process of toilet training and only uses pamper at nighttime. Patient sleeps 8-9 hours at night and 2 hours nap during the day. Patient rides in the back seat of the car. All cabinets are locked at home and house has smoke alarms. | ||
| HPI: (must include all components)2 y/o male born at 39 weeks gestation via uncomplicated vaginal delivery. Seen in the office accompanied by mother for follow up appointment and labs results. Patient had been seen 1week ago due to complaints of frequent nose bleeds. Last episode 1 weeks ago while in office in the presence of the doctor. Bleeding is usually unilateral but can be present in any nostril. Bleeding is usually of short duration and can be easily controlled with finger pressure. Mother denies bruises, easily bleeding, teeth bleeding or melena. Labs ordered showed an unremarkable complete blood count with only abnormal elevation of PT at 50. | ||
| Medications:None | ||
| PMHX:Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: NoneImmunizations: Up to date | ||
| Family HistoryMother is 28 years old and does not have a past medical historyFather is 36 years old and is healthy. However, he does report similar episodes of nose bleeds since he was a child. He was told it was nose dryness and was never diagnosed with any other diseaseMaternal grandmother suffers has GERD.Maternal grandfather suffers from Hypertension.Paternal grandmother has HypertensionPaternal grandfather has hypertension and suffered a TIA 3 years ago but is stable.History of bleeding disorder of his maternal uncle | ||
| Social History Patient lives with both parents and maternal grandmother in a rented house. Both parents are accounting and they are initiated their own office. He goes to daycare since he was 1 year and 6-month-old. Mother reports no guns at home, and they have smoke and CO2 alarms at home. Patient is an only child. He wears helmets for safety when riding bikes. Both parents are highly involved in his care. | ||
| ROS | ||
| GeneralDenies weakness, fever, fatigue, night sweats or malaise | CardiovascularDenies abnormal heart beats, murmurs, or chest trauma | |
| SkinDenies rash, hives, urticarial, bruises or lesions | RespiratoryNegative for coughing up blood, respiratory distress or increased respirations | |
| EyesDenies eye redness or discharge | GastrointestinalDenies blood in the stool, nausea, vomiting or anorexia | |
| EarsDenies ear tugging or discharge | Genitourinary/GynecologicalDenies cloudy urine or dysuria | |
| Nose/Mouth/ThroatMother reports several episodes of epistaxis.Negative for nasal congestion, mouth sores or dysphagia | MusculoskeletalDenies limitation of ROM or joint deformities | |
| BreastNot examined | NeurologicalDenies epilepsy, syncope, hyperactivity or loss of consciousness | |
| Heme/Lymph/EndoDenies anemia, unusual bruising, recent blood transfusions, enlarged lymph nodes, increased thirst. Positive for nose bleeds | PsychiatricDenies sleep problems, anxiety or depression | |
| OBJECTIVE | ||
| Weight 35 lbs | Temp 98.3 | BP106/67 |
| Height91.44 cm | Pulse 86 | Resp/ 18 |
| General Appearance and parent‐child interactionHealthy appearing toddler, sitting on his mother’s lap with positive interaction with mother | ||
| SkinNormal skin turgor, with warm and intact skin. Capillary refill 2 seconds | ||
| HEENTNormocepahlic head with even hair distribution. Pupils PERRLA. EOMs intact. Tympanic membranes pink. Patent nasal nares. Septum midline. No obstruction or foreign body observed. Mouth with all teeth and molars without carries. No JVD. Neck supple and with full ROOM. |
The post . Patient is in the process of toilet training and only uses pamper at nighttime. appeared first on MBA Nursing Papers.