Pediatric SOAP Note
NP Student Name: Skye Acho Child’s Initials: TA DOB: 2/05/20017
Clinical Date: 6/15/19 Age: 24 months old Place of Born:
Sex: Type of Soap Note:
Week Soap Project: W1 W3 W7 W8 M _X Well child visit
F Sick visit X
SUBJECTIVE
Historian: Patient’s mother
Present Concerns/CC: “abdominal pain x2 days”
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): Patient’s mother states that TA is well-behaved, has good
appetite, drinks adequate amount of fluid, sleeps well during night.
Safety Practices: Child sits in the back seat with a forward-facing car seat. Neighborhood is
considered generally safe.
Changes in daycare/school/after-school care: Pt mother states unable to afford day care and
neighbors or mother’s boyfriend babysit the children.
Sports/physical activity: Mother states “normally T.A. is a very active and playful toddler”
Developmental History: Mother states that he is developmentally delayed due to the patient having
Down Syndrome. Mother states he does not speak that much and does not pick things up as quickly.
In addition, patient does fall and trip often, and bumps into things but this is the first time the
patient is requiring medication attention.
HPI: Tommy, a 26-month-old male with Down Syndrome, was brought into the ED by his mother who
reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic,
sweating, breathing rapidly and has diminished urine output. All symptoms started soon after his
“falling out of the bed during his nap.” She denies associated head trauma but claims he is not
eating or drinking. She denies prior injuries that required medical attention. PMH is notable for post
atrial-septal defect repair with transient CHF as an infant. The child appears listless and pale. Exam
reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly
distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to
palpation with diffuse tenderness, guarding, and rebound tenderness. A reducible 2.0cm-umbilical
hernia is present.
Medications: Patient is not on any medications. (Med, dosage, & reason for med)
PMH:
Allergies: None
Chronic Illnesses/Major traumas: AV septal defect, transient CHF,
heart murmu Hospitalizations/Surgeries: AV septal defect repair
Immunizations: Up-to-date
Family Medical History: Mother has a history of anemia. Unknown medical history of father, father is
not
currently involved. Patient has 5 year old sibling with asthma, and, a 6 month years old, in good
health.
Current living situation/partner/marital status: Pt mother is a single-mother but is in a relationship
with 6- month-old siblings father. Mother currently employed, but states she is unable to
afford daycare.
Neighbors and mother boyfriend babysit children. Pt mother states boyfriend does not like
to babysit because the kids whine at times, and he can’t tolerate it.
Educational level (as appropriate): Pts mother graduated high school
Occupational history (as appropriate): Mother currently employed, but states she is unable to
afford daycare.
T
Substance use/abuse (ETOH, tobacco, and marijuana): Mother denies substance, ETOH, or
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415098/SU-NSG6435-W7docx/
, marijuana use for both her and the father. Mother and boyfriend both smoke. Pt is exposed
to second hand smoking
Firearms in home: No firearms in the house per mother
his s tu dy so urc e w a s d ow n lo ad ed b y 10 00 0 0 85 2 6 8 10 95 fr o m
CoS ura sfee Htye ro
s ta
.c tom
u s on: P
1 t2 m
-0 2o -2th
0 2e 2r 2 fe
0 :0e8 l :s 47s G
a fMe Tin- 0c 6:0
om 0
m u nit ya n d su rr o u n d i n g n e i g h b o rh o o d a nd has adequate
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415098/SU-NSG6435-W7docx/
NP Student Name: Skye Acho Child’s Initials: TA DOB: 2/05/20017
Clinical Date: 6/15/19 Age: 24 months old Place of Born:
Sex: Type of Soap Note:
Week Soap Project: W1 W3 W7 W8 M _X Well child visit
F Sick visit X
SUBJECTIVE
Historian: Patient’s mother
Present Concerns/CC: “abdominal pain x2 days”
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): Patient’s mother states that TA is well-behaved, has good
appetite, drinks adequate amount of fluid, sleeps well during night.
Safety Practices: Child sits in the back seat with a forward-facing car seat. Neighborhood is
considered generally safe.
Changes in daycare/school/after-school care: Pt mother states unable to afford day care and
neighbors or mother’s boyfriend babysit the children.
Sports/physical activity: Mother states “normally T.A. is a very active and playful toddler”
Developmental History: Mother states that he is developmentally delayed due to the patient having
Down Syndrome. Mother states he does not speak that much and does not pick things up as quickly.
In addition, patient does fall and trip often, and bumps into things but this is the first time the
patient is requiring medication attention.
HPI: Tommy, a 26-month-old male with Down Syndrome, was brought into the ED by his mother who
reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic,
sweating, breathing rapidly and has diminished urine output. All symptoms started soon after his
“falling out of the bed during his nap.” She denies associated head trauma but claims he is not
eating or drinking. She denies prior injuries that required medical attention. PMH is notable for post
atrial-septal defect repair with transient CHF as an infant. The child appears listless and pale. Exam
reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly
distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to
palpation with diffuse tenderness, guarding, and rebound tenderness. A reducible 2.0cm-umbilical
hernia is present.
Medications: Patient is not on any medications. (Med, dosage, & reason for med)
PMH:
Allergies: None
Chronic Illnesses/Major traumas: AV septal defect, transient CHF,
heart murmu Hospitalizations/Surgeries: AV septal defect repair
Immunizations: Up-to-date
Family Medical History: Mother has a history of anemia. Unknown medical history of father, father is
not
currently involved. Patient has 5 year old sibling with asthma, and, a 6 month years old, in good
health.
Current living situation/partner/marital status: Pt mother is a single-mother but is in a relationship
with 6- month-old siblings father. Mother currently employed, but states she is unable to
afford daycare.
Neighbors and mother boyfriend babysit children. Pt mother states boyfriend does not like
to babysit because the kids whine at times, and he can’t tolerate it.
Educational level (as appropriate): Pts mother graduated high school
Occupational history (as appropriate): Mother currently employed, but states she is unable to
afford daycare.
T
Substance use/abuse (ETOH, tobacco, and marijuana): Mother denies substance, ETOH, or
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415098/SU-NSG6435-W7docx/
, marijuana use for both her and the father. Mother and boyfriend both smoke. Pt is exposed
to second hand smoking
Firearms in home: No firearms in the house per mother
his s tu dy so urc e w a s d ow n lo ad ed b y 10 00 0 0 85 2 6 8 10 95 fr o m
CoS ura sfee Htye ro
s ta
.c tom
u s on: P
1 t2 m
-0 2o -2th
0 2e 2r 2 fe
0 :0e8 l :s 47s G
a fMe Tin- 0c 6:0
om 0
m u nit ya n d su rr o u n d i n g n e i g h b o rh o o d a nd has adequate
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415098/SU-NSG6435-W7docx/
