I. Identifying Data: A. Initials: NM Age: 8 YEARS DOB: 03 ...

Complete SOAP Note (PEDIATRIC)

Student: Sheri Harrison

Course: NURS7446 Fall 2014

Date:

11/22/2014

Patient: (Select Patient)

Location: All Med for Women Preceptor: (Select)

PEDIATRIC CLIENT DATABASE

(Complete SOAP Note Format)

Clinical

Setting

Selma Pediatrics

Acute

Care

Primary

Care

SUBJECTIVE DATA

I. Identifying Data:

A. Initials:

NM Age: 8 YEARS DOB: 03-25-2006 Sex: Male

B.

Mother and Patient

Informant

C. Insurance:

Reliability

Race/Ethnic

African American

Origin:

RELIABLE

ALACAID

II. Chief Complaint: Reason or reasons for seeking medical attention. To be recorded in informant¡¯s own words.

"cough"

III. History of Present Illness: Chronological narration of client¡¯s present illness, including the seven variables.

The patient's mother reports coughing x 1-2 days. The symptoms have been moderate. It is described to be

unproductive, no hmoptysis. There are no preciptiating factors. There are no ameliorating factors. Denies fever. No

chills, No night swears. Theree is no unexplanined weight loss. Patient does not have associated sinus congestion,

runny nose, sore throat, chest pain, wheezing, or dyspnea. He has tried no medicaitons for relief of symptoms. He has

no current or past smoking exposure. Patient has not had occupational exposure and denies being around anyone sick.

Patient denies recent travel. No pets in the home.

IV. Past Medical History

Prenatal History

Mother reported seeking regular prenatal checkups. Denies any gestational diabetes, hypertension, or preclampsia

during pregnancy.

Perinatal

Patient was born via vaginal delivery at 39 weeks with out difficulty.

Neonatal

n/a

Communicable Diseases

Patient has no known drug allergies.

Patient has a history of asthma, mild persistent Step 2 control. He was diagnosed 2 years ago and was prescribed ProAir (SABA) at this time. Singulair was later added for better control and is being managed. Medications include Pro-Air

inhaler as needed, Singuliar 5mg chewable tablet PO every PM.

Developmental

Last screening was in March 2013. Screening for 8 year old include height, weight, blood pressure, Pure-tone

audiometry, height, weight, BMI, cholesterol screening, and milestones were checked at this time. This also included a

scoliosis screening which was normal. Milestones for patient include catching a ball with both hands, tieing his shoes,

demonstates some independence from parents, and talk clearly and answer questional appropriately.

Immunizations (type and date(s) administered)

Patient is up to date with all recommended immunizations for his age. He has not received the flu vaccination for this

season and mother is agreeable to receiving this today in clinic.

Operations & hospitalizations

Type

Age(s)

Response to

anesthesia

No previous hospitalizations

Onset of Menses:

Dysmenorrhea?

Pregnancies

Miscarriages

Abortions

Social History

Personality

Pleasant affect. He is able to sit still during examination. He follows commands and answers quesitons

appropriately.

Habits

Patient enjoys playing with his friends. Plays basketball on a team at the YMCA for the past 3 years.

Mental Health

Patient is mentally appropriate with no delays noted.

School grade

AB honor roll

Peer relationships

He says he has friends at school and is well liked. Mother agrees that he has an out going personality

with no history of getting in trouble at school or home.

Failed any grade?

(if so explain)

Family History

Parents¡¯ ages:

32

marital status:

single

Step Parents /guardian

ages:

Siblings¡¯ ages:

occupations:

stay at home mother

occupations

no sibblings Family position:

Sibling relationships:

Parents¡¯ health (general plus any chronic illnesses/health conditions):

Mother

history of asthma as a child, hypertension

Father

unknown

Grandparents¡¯ health

Maternal

hypertension, stroke

Paternal

unknown

Review of Systems: for all systems

General

Ears

Breasts

Urinary

Musculoskeletal

Skin

Nose & Sinuses

Respiratory

Genital, Male

Neurologic

Psychosocial

Developmental

Head

Mouth & Throat

Cardiac

Genital, Female

Hematologic

Eyes

Neck

GI

Peripheral Vascular

Endocrine

1). General Appearance: He has normal appearance. Denies chills, fever or recent weight changes.

2). Denies any double or blurred vision, or redness,

3). Ears, nose, mouth, and throat - Denies any hearing loss or exposure to loud noises. Does not wear hearing aids.

Denies any vertigo, pain, or presence of infection to ears. Patient denies any loss of smell, discharge, epstaxis. Patient

brushes her teeth twice daily and flosses a few times a week. Denies any lesions. Mother reports he visits the dentist

every 6 months for routine cleaning.

4). Cardiovascular - Denies any chest pain, murmurs, palpitations, dyspnea, or activity intolerance.

5.) Respiratory - Denies any exposure to tobacco smoke, No SOB, wheezing, hemoptysis. Reports cough,

nonproductive in nature.

6). Gastrointestinal - Denies any melana, abdominal pain, nausea, vomiting, or diarrhea.

7). Genitourinary - Denies any dysuria, hematuria, polyria, incontinence, or flank pain.

8). Musculoskelatal - Denies any joint or back pain or stiffness. Has full ROM. Patient reports he uses his seatbelt

regular and wears a helmet when riding his bicycle.

9). Integumentary -Denies any rash, itching, hair loss, nail deformity, or lesions.

10). Denies any muscle weakness, syncope, stroke, seizures, paresthesias, involuntary movements or tremors, los of

memory, or headaches.

11). Psychiatric - Denies any depression, anxiety, nervousness, insomnia, agressvie behavior, or mental history.

12). Endocrine - Denies any thyroid, cold or heat intolerance, diabetes, polydipsia, polyphagia, polyuria,changes in skin,

hair or nail texture. Denies any unexplained weight change.

13). Hematoloic/lymphatic - Denies any brusing, unusual bleeding, fatique, history of anemia, blood transfusions,

swollen and/or tender glands. Last HCT is unavailable.

14). Patient is postive for occasional allergies which at times triggers his asthma. Mother states he is well controlled on

Singulair with less than 2 times weekly use of his SABA (Pro-Air).

Physical Examination

Vital signs

Temp.

Respirations

not done

Blood pressure

Pulse oximeter

98.3

100

%

22

(crying?)

no

n/a

cms.

Head Circumference

Length/height

cms %

96

Heart rate

%

Weight

36.36

kg %

BMI 23.42

Skin

No rashes, no lesions.

Head

Head inspections reveals no abnormality. Normocephalic. No sinus tenderness

Eyes

Eye muscles and extraocular movements reveals EOMs are intact. Present red reflex.

Conjunctivae ae anicteric and have normal reflections. Pupils are equal, round, and reactive to

light and accomodation. There is no discharge from eyes.

Ears

TM on the right and left are clear. External ear is clear.

Nose

Boggy swollen pink turbinatess. No polpys, or septal deviation. Mucousa moist.

Mouth & Throat

Pharynx not injected. Some post nasal drip.

Neck

Thyroid is normal in size, shape and texture without masses. The neck is supple. The ROM of

the cervical spine is normal with 60 degrees, flexion 50 degrees, rotation 80 degrees and lateral

flexion 45 degrees.

Respiratory

Clear to auscultation. Air movement is normal. Chest symmetrical.

Breasts & Axillae

There is no nipple discharge. No lumps/masses present. Fibroadenoma is not present. No

fibrocystic change noted. There is no gynecomastia. There is no breast tenderness.

Cardiovascular

No murmurs present. Pulses are 2 plus bilateral. Regular rate and rhythm.

Abdomen

Inspection of abdomen is unremakable. There is no distension, rigidity, tenderness, asymmetry

or masses. There is no tenderness over McBurney point. Bowel sounds are normoactive.

Musculoskeletal

Examination of extremities and joints reveals normal ROM. No edema present.

Neurologic

There is no decreased LOC. He is alert and oriented x 3. Cranial nerves II to XII are within

normal limits. Normal tone and gait steady. Reflexes are equal and symmetric billaterally.

Sensory exm is within normal limits.

Lymph

There is no lympadenopathy.

Genitourinary

deferred

Rectal

deferred

Screening/Diagnostic Testing:

Date of last vision screening:

03/2013 Results:

AOD 20/20

Date of last hearing screening:

03/2013 Results:

passed

Date of last developmental screening

03/2013 Results:

normal

Diagnostic Tests:

Assessment:

Health Maintenance:

Influenza vaccine V04.81 0

Acute Self Limiting:

Asthma 493.90

Cough 786.2

Allergic sinusitis 477.9

Plan:

Office visit, Established patient 992.14

Asthma and cough- Provided couseling related to asthma which included teaching correct technique of inhaler and

return demonstration by patient. Triggers were also discussed that brings on exertional symptoms. Patient plays

basketball and needs to have inhaler abailable. Refills sent to patient's pharmacy of choice for ProAir HFA

90mcg/actuation aerosol inhaler 2 Puff every 4 hours PRN for 30 days; 1 refill. Price is $54.49 per 1 inhaler.

Refill of singulair 5mg chewable tablet 1 packet at bedtime for 90 days, dispense 90 packets. 1 package of of 30

packets retails at $196.41. This is a maintenance drug and should be taken daily. Dose should not exceed 5mg/day.

Patient instructed to not use for exertional asthma

Allergic Rhinitis - Cetirizine 10mg tablet once a day x 30 days, dispense 30 tabs, no refills. $18.99 for a package of

30pills; OTC ; (Allegen avoidance is the most effective from of treament; effective long-erm management may prevet or

reduce general respiratory tract inflammation thereby decreasing incidence and worsening asthma)

1. Flu vaccination administered after consent signed by mother. Flu vaccination handout given to mother. Since the

patient has history of asthma, a yearly flu vaccination is recommended.

Follow up in clinic in 3 months for evaluation of asthma control. May return to clinic if needed for worsening symptoms

or if symptoms do not improve with treatment.

Evaluation:

Patient's mother has good recall of all instructions provided. Patient demonstrated correct use of inhaler.

generated in Medatrax

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