Pediatric SOAP Note SU_NSG6435_W7

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: Week Soap Project: W1 W3 W7 W8 Sex: M _X F Type of Soap Note: Well child visit 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. Substance use/abuse (ETOH, tobacco, and marijuana): Mother denies substance, ETOH, or 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 sStuadyfesotyurcsetawtaus sd:owPntlomadoedthbeyr10fe00e0l0s84s7a0f9e71in52cfroomm mCouurnsietHuonrr1o0u-2n4d-2i0n2g2 1n5e:4i2g:h32bGoMrhTo-o0d5:0a0nd has adequate OBJECTIVE Weight: 22 lbs- less than 5th percentile REVIEW OF SYSTEMS BP: 68/40 General: BMI: 19.7- 97th percentile Denies fever and chills, weight change or night Temp: 97.9 F Cardiovascular: History of ASD, but repair ed. Denies history of Height: 2’ 4’’ sweats. Pt mother has complaints of increased Pulse 140 bpm Respirations: 50 hypertension, shortness of breath, edema, General Appearance & parent‐child interaction: 14- whining, poor sleep, low energy, and poor appetite. year-old male child appearing in discomfort from right tachycardia, palpitations, chest pain. aSnkkilne: pain. Patient is awake and oriented. Patient and aHnisottohreyr oafnddiaspeeermrahsahpepsy,.bPuat tnieonct oismdprleasinstesdoaf prapsrohpriat Crtaobmleplsaiitntitnsgoof ncleaxmammyinsaktino.nDbeendi.eUs pboleneadsinsge,ssm bmeoalreins,gopreler spito. ns. moRtheesrpsireaetmortyo: have a comfortable relationship with one e fCorotmheplaseinatsoonf.rAapleidrt Ddexn4ie.sPwathieenetziisng or enct,oguagiht iunngs, theeamdyopdtuyesitso. right ankle being non-weight Head: Breast: SDkeinni:eSs kainyisdceofoorlm, sitwieesa, tlyesainodnss,liegdhetlmy Tehsoraco Poantiheenat a diffuse diaper rash. Faint circumferential ligature marks. appropriate for race- no cyanosis, jaun toDmeyfesrcreadr .consistent with history of AV-septal repair. macular discolorations at wrist consistent with aging dice, or pallor noted. Capillary refill 4 seconds in toes. Eyes: Gastrointestinal: HDeaedn:ieNsochvaisnibgle isncavilsinioens,s,deizdzeinmeas,sm, balussrreesd, lourmdposu,bdleefo . No signs of head trauma. Down Syndrom normocephalic, atraumatic. Hair is normal thickness and rmCitoiems,pslacianrts,oraf sahbedso,mnienvail, poar ionthxe2r ldeasyiosn, semnoetseids.x1H.ead e faDceiensie:sfladtiafarrchee,au,pcsolannstipnagtieoyneso.r bHlaecakdtiasrry stools. diDsterinbiuetsiohnisptoartyteornf GfoEr RpaD gender. Posterior and anEtaerrsio:r fontanel’s are closed. Musculoskeletal: EDyeensie: sCaonnyjuenacrtivinafecistiopninsk, ewairthanchoed,S w PERRLA. Upward slanting with small skin folds on the hiDtee. nCieosrnaenadisjotirnatnsswpealrleinngt oarndpasimn.oDEsyehsistaorrey of res. Ears: Low set ears, no deformities or edema, no discha rge noted. With otoscope, normal appearing external aNuodsiteo/rMy ocuantha/lTs,htryomapt:anic membrane translucent, pinki lDanednmieasrtkhsroaantdpeaains,ilnyavsisaul adlrizaeinda,gceo,nbeleoef dliignhgt opfresent. sh-Ngerauyroinlocgoilcoar,l:no scarring or discharge, normal Patient has poor verbal communication due to Nose: Nose is midline, no discharge noted or nasal flar gums. Denies dysphagia. Denies any symptoms of over the frontal or maxillary sinuses. Septum is intact. sinusitis. ing. Turbinate’s pink, bilaterally. No edema or tenderness diagnosis of Down Syndrome. Denies dizziness or loss of consciousness. No history of seizures or syncope. Denies tremors. Denies lack of coordination. Throat/Mouth: Tongue pink and symmetrical. No eryth Genitourinary/Gynecological: palate has texture. Tonsils are pink and smooth, no enl Complaints of decrease frequency of urine, foul swelling of gums noted. odor, and dark urine noted. Denies dysuria, hematuria or urgency. Denies history of UTI. ema noted. Mucous membranes pink and moist. Hard Heme/Lymph/Endo: argement noted. Dental caries noted. No bleeding or Complaints of abdominal bruising. Denies fever. Denies lymph node tenderness or swelling. Denies history of thyroid disease, anemia or diabetes. Neck: Full range of motion in the neck. Pre-auricular, po Developmental Problems: tonsillar, superficial cervical, posterior cervical, supraclavi Developmental delayed related to diagnosis of Down Thyroid WNL to palpations- no neck masses noted, non Syndrome. st auricular, occipital, submental, submandibular, Behavioral Status/Psychiatric: cular lymph nodes are not palpable, enlarged, or tender. Complaints of poor sleep, increased whining x 2 days. -tender. Trachea intact. Denies depression or suicidal ideations. Cardiovascular: Early systolic murmur is present. No hypertension or tachycardia. The point of maximal impulse (PMI) is in the 5th intercostal space at the mid clavicular line. Pulses weak throughout. Normal capillary refill for fingers. Capillary refill for toes is 4 seconds. Respiratory: Tachypnea noted, non-labored movement of chest wall. Upon palpation, non-tender to chest wall, clavicle. Upon percussion, anterior lung fields are resonant. Liver is dull to percussion. Rest of lung fields are resonant. Breath sounds clear throughout, unlabored, no wheezing or crackles noted. No increased work of breathing. Lungs are clear throughout, no adventitious breath sounds heard. Gastrointestinal: Ecchymosis overlying the epigastrum measuring 10 cm in longest diameter and oval shape. Abdomen is distended, firm. Diffuse tenderness to palpation with associated guarding and rebound. Reducible 2 cm umbilical hernia noted. Breast: N/A