NSG6435 SOAP 2 PEDIATRIC NOTE LATEST2022-2023
Pediatric SOAP Note
NP Student Name: Chantal Monde Child’s Initials: B.W. DOB: 06/05/2013
Clinical Date: 8/15/2018 Age: 5yrs old Place of Born: Oviedo, FL
Week 6 Assignment Sex: Male
SUBJECTIVE
Historian: Patient/Mother
Present Concerns/CC: “diarrhea, vomiting and fever, abdominal pain”
, NSG6435 SOAP 2 PEDIATRIC NOTE LATEST2022-2023
Child Profile:
5 years old Spanish male who is currently in kindergarten reported by mother to have appropriate
social behavior for his age. She also reports that he completes his chores at home with minimal
assistance. His diet consists of Macaroni with cheese, been, lean meats, vegetables and pasta, and
rice. She also states that he has no difficulty sleeping; his bedtime is between 9:00 pm and wakes
up around 8:00 am. Mother also reports that he. is very active, he loves to be outdoor playing. He
loves playing games and watch video game. The mother reports that he has good relationship with
his cousin and good interaction with his peers. She further reports safety measures such as
wearing seatbelt for car rides and helmets when riding his scooter/ bicycle. She also acknowledges
taking all safety measures to make sure her children are safe and are always in a safe
environment.
HPI: (must include all components) A 5 years old male accompanied with her mother to the
clinic with presenting symptoms of vomiting, watery diarrhea, fever, loss of appetite and stomach
cramping x 1 day. The mother said the patient has developed fever with Tmax 101.7 relieved with
Tylenol and he reports his abdominal pain at a 6/10 on the FACES pain scale. The patient ate Sushi
and salad for dinner at home with her family and nobody else sick at home.
Daily Living: preschooler, play with stuffed animals, reads book, play with stickers, go
on a play date, coloring books, ride tricycle,
Safety Practices: Bike Safety always wear a helmet when riding a bike.
teach him to always stop at the curb and never cross the street without a grown-up.
Water Safety. never let him or her swim alone.
Fire Safety. Teach your child not to play with matches or lighters, and keep matches and lighters
out of your child's reach.
Car Safety. The safest place for all children to ride is the back seat and correctly USE a
car safety seat
Pediatric SOAP Note
NP Student Name: Chantal Monde Child’s Initials: B.W. DOB: 06/05/2013
Clinical Date: 8/15/2018 Age: 5yrs old Place of Born: Oviedo, FL
Week 6 Assignment Sex: Male
SUBJECTIVE
Historian: Patient/Mother
Present Concerns/CC: “diarrhea, vomiting and fever, abdominal pain”
, NSG6435 SOAP 2 PEDIATRIC NOTE LATEST2022-2023
Child Profile:
5 years old Spanish male who is currently in kindergarten reported by mother to have appropriate
social behavior for his age. She also reports that he completes his chores at home with minimal
assistance. His diet consists of Macaroni with cheese, been, lean meats, vegetables and pasta, and
rice. She also states that he has no difficulty sleeping; his bedtime is between 9:00 pm and wakes
up around 8:00 am. Mother also reports that he. is very active, he loves to be outdoor playing. He
loves playing games and watch video game. The mother reports that he has good relationship with
his cousin and good interaction with his peers. She further reports safety measures such as
wearing seatbelt for car rides and helmets when riding his scooter/ bicycle. She also acknowledges
taking all safety measures to make sure her children are safe and are always in a safe
environment.
HPI: (must include all components) A 5 years old male accompanied with her mother to the
clinic with presenting symptoms of vomiting, watery diarrhea, fever, loss of appetite and stomach
cramping x 1 day. The mother said the patient has developed fever with Tmax 101.7 relieved with
Tylenol and he reports his abdominal pain at a 6/10 on the FACES pain scale. The patient ate Sushi
and salad for dinner at home with her family and nobody else sick at home.
Daily Living: preschooler, play with stuffed animals, reads book, play with stickers, go
on a play date, coloring books, ride tricycle,
Safety Practices: Bike Safety always wear a helmet when riding a bike.
teach him to always stop at the curb and never cross the street without a grown-up.
Water Safety. never let him or her swim alone.
Fire Safety. Teach your child not to play with matches or lighters, and keep matches and lighters
out of your child's reach.
Car Safety. The safest place for all children to ride is the back seat and correctly USE a
car safety seat
