Pediatric
Pediatric SOAP NOTE- DENIS SOAP NOTE- 1
Pediatric SOAP Note
Name
Instructor
Institutional Affiliation
Date
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:48:50 GMT -06:00
https://www.coursehero.com/file/63151132/Pediatric-SOAP-NOTE-DENISdocx/
, PEDIATRIC SOAP NOTE 2
Name: C.M. Date:5/1/2020
Sex: M Age/DOB/Place of Birth: 8 years/4/21/2012
SUBJECTIVE
Historian: Mother and patient
Present Concerns/CC:
“Cough”
Child Profile:
C.M. was borne at term (40-week gestation) via spontaneous vertex delivery to a 21-year-
old mother G1P1 who had the first prenatal visit during the second trimester. Prenatal
screening for the mother was non-remarkable and negative for syphilis and other infections.
The birth weight was 3.2 kg and length of 45 cm. There were no complications related to
birth, as APGAR score was 7 at 1, 9 at 5, and 10 at 10 minutes. The mom states C.M.
breathed spontaneously following birth with both mother and the baby being discharged
after two days after newborn screen. The patient has had a normal development and has been
to no daycare. He is in grade 7and is social, as he plays with other children normally. Last
developmental check was a month ago. Sat at age 6 months, walked at age 15 months, spoke
about 2 words by 1 year of age, and was able to brush his teeth by 2 years.
HPI:
C.M. is an 8-year-old boy of African American descent presenting with a 2-day history of cough. The
mother reports that the symptoms are moderate, with the cough being unproductive with no associated
hemoptysis. The mother also reports neither precipitating nor ameliorating factors. The patient denies
any history of fever, chills, or night sweat. He also denies any history of sore throat, runny nose,
wheezing, chest pain, or dyspnea. The mother reports that no medications have been tried to relieve
C.M.’s symptoms. The patient also has no history of exposure to cigarette smoke and occupational
exposure to toxic fumes. He also denies any history of contact with a sick individual and recent travel.
The patient has no pet at home.
Medications:
Currently, the patient is on no medications.
PMH:
The patient has no past medical history.
Allergies: The patient has no known
allergy. Medication Intolerances:
None
Chronic Illnesses/Major
traumas: None
Hospitalizations/Surgeries:
None
Immunizations: All up-to-
date including HepB (at
birth), 2nd dose at 2
months3rd dose at months;
Rotavirus and inactivated
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:48:50 GMT -06:00
https://www.coursehero.com/file/63151132/Pediatric-SOAP-NOTE-DENISdocx/
Pediatric SOAP NOTE- DENIS SOAP NOTE- 1
Pediatric SOAP Note
Name
Instructor
Institutional Affiliation
Date
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:48:50 GMT -06:00
https://www.coursehero.com/file/63151132/Pediatric-SOAP-NOTE-DENISdocx/
, PEDIATRIC SOAP NOTE 2
Name: C.M. Date:5/1/2020
Sex: M Age/DOB/Place of Birth: 8 years/4/21/2012
SUBJECTIVE
Historian: Mother and patient
Present Concerns/CC:
“Cough”
Child Profile:
C.M. was borne at term (40-week gestation) via spontaneous vertex delivery to a 21-year-
old mother G1P1 who had the first prenatal visit during the second trimester. Prenatal
screening for the mother was non-remarkable and negative for syphilis and other infections.
The birth weight was 3.2 kg and length of 45 cm. There were no complications related to
birth, as APGAR score was 7 at 1, 9 at 5, and 10 at 10 minutes. The mom states C.M.
breathed spontaneously following birth with both mother and the baby being discharged
after two days after newborn screen. The patient has had a normal development and has been
to no daycare. He is in grade 7and is social, as he plays with other children normally. Last
developmental check was a month ago. Sat at age 6 months, walked at age 15 months, spoke
about 2 words by 1 year of age, and was able to brush his teeth by 2 years.
HPI:
C.M. is an 8-year-old boy of African American descent presenting with a 2-day history of cough. The
mother reports that the symptoms are moderate, with the cough being unproductive with no associated
hemoptysis. The mother also reports neither precipitating nor ameliorating factors. The patient denies
any history of fever, chills, or night sweat. He also denies any history of sore throat, runny nose,
wheezing, chest pain, or dyspnea. The mother reports that no medications have been tried to relieve
C.M.’s symptoms. The patient also has no history of exposure to cigarette smoke and occupational
exposure to toxic fumes. He also denies any history of contact with a sick individual and recent travel.
The patient has no pet at home.
Medications:
Currently, the patient is on no medications.
PMH:
The patient has no past medical history.
Allergies: The patient has no known
allergy. Medication Intolerances:
None
Chronic Illnesses/Major
traumas: None
Hospitalizations/Surgeries:
None
Immunizations: All up-to-
date including HepB (at
birth), 2nd dose at 2
months3rd dose at months;
Rotavirus and inactivated
This study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:48:50 GMT -06:00
https://www.coursehero.com/file/63151132/Pediatric-SOAP-NOTE-DENISdocx/
