Pediatric SOAP note
Name: TA Date: 12/06/19
Sex:
DOB- DOB: 08.01.17 AGE-26 Months old.
Male
SUBJECTIVE
Historian: Patient’ mother
Present Concerns/CC: "Tommy is not himself" my child has been whining and refusing to eat. He
seems. When I looked on his tummy, I found a big bruise”
Child Profile:
Sexual history- Mom denies sexual abuse
ADLs- Some developmental delay, but able to eat finger foods, drink from a sipping cup
Safety- No exposure to second-hand smoke, guns or chemicals. Uses car seat and helmet when riding
Milestone-Physical and developmental delay in conjunction with down syndrome
HPI:
26 months male here with his mother complaining of abdominal pain, irritability, reduced appetite, dark
and reduced urinary output, nausea and vomiting that has been ongoing for two days. Mom stated
symptoms started since patient fell from his 3 feet crib. Other acute symptoms noted are tachypnea,
hypotension and tachycardia. Denied any trauma to head, diarrhea and difficulty breathing.
Medications
No home medications
, Pediatric SOAP note
PMH:
Allergies: NKDA
Chronic Illnesses/Major
ASD
Traumas:
Post fall
Hospitalization/ Surgical
ASD Repair
Immunizations:
Up to date
Family/Medical History
TA who has down syndrome lives with his mother, and his two other siblings. TA had atrial septic defect
as a baby and has since been repaired. His mother is anemic. His 5-year-old brother is asthmatic. No
known medical on his 6 months old brother. No know medical history on his father. His mother, a high
school graduate works a cashier.
Social History
TA is surrounded by his family, mother’s boyfriend and neighbors. Usually termed “happy and clumsy
baby” by mom.
ROS
General Cardiovascular
Admits to low energy, no appetite and Admits to repaired ASD, heart murmur and
irritability. Denies weight loss heart failure. Denies chest pain, palpitations,
PND, orthopnea, or swelling to body parts.
Skin Respiratory
Admits to easily bruise. Old scare to chest Denies any pulmonary trauma, SOB or difficulty
breathing.
Eyes Gastrointestinal
Denies trauma to eye. No tearing or difficulty Admits to abdominal pain that started 2 days post fall
with vision. from
Name: TA Date: 12/06/19
Sex:
DOB- DOB: 08.01.17 AGE-26 Months old.
Male
SUBJECTIVE
Historian: Patient’ mother
Present Concerns/CC: "Tommy is not himself" my child has been whining and refusing to eat. He
seems. When I looked on his tummy, I found a big bruise”
Child Profile:
Sexual history- Mom denies sexual abuse
ADLs- Some developmental delay, but able to eat finger foods, drink from a sipping cup
Safety- No exposure to second-hand smoke, guns or chemicals. Uses car seat and helmet when riding
Milestone-Physical and developmental delay in conjunction with down syndrome
HPI:
26 months male here with his mother complaining of abdominal pain, irritability, reduced appetite, dark
and reduced urinary output, nausea and vomiting that has been ongoing for two days. Mom stated
symptoms started since patient fell from his 3 feet crib. Other acute symptoms noted are tachypnea,
hypotension and tachycardia. Denied any trauma to head, diarrhea and difficulty breathing.
Medications
No home medications
, Pediatric SOAP note
PMH:
Allergies: NKDA
Chronic Illnesses/Major
ASD
Traumas:
Post fall
Hospitalization/ Surgical
ASD Repair
Immunizations:
Up to date
Family/Medical History
TA who has down syndrome lives with his mother, and his two other siblings. TA had atrial septic defect
as a baby and has since been repaired. His mother is anemic. His 5-year-old brother is asthmatic. No
known medical on his 6 months old brother. No know medical history on his father. His mother, a high
school graduate works a cashier.
Social History
TA is surrounded by his family, mother’s boyfriend and neighbors. Usually termed “happy and clumsy
baby” by mom.
ROS
General Cardiovascular
Admits to low energy, no appetite and Admits to repaired ASD, heart murmur and
irritability. Denies weight loss heart failure. Denies chest pain, palpitations,
PND, orthopnea, or swelling to body parts.
Skin Respiratory
Admits to easily bruise. Old scare to chest Denies any pulmonary trauma, SOB or difficulty
breathing.
Eyes Gastrointestinal
Denies trauma to eye. No tearing or difficulty Admits to abdominal pain that started 2 days post fall
with vision. from
