Pediatric SOAP Note: Comprehensive Exam
NAME:
College of Nursing and Health Innovation, University of Texas at Arlington
NURS 5130: Pediatric Health Assessment Lab
Courtney Shea Werner APRN, MSN, CPNP
July 16, 2025
, SOAP Note Form
S/ Identifying Information: (initials, age/DOB, gender, Family Hx:
reliability)
L.G., 8 year-old, Female, Presenting with mother, Reliable Mother and Father: None
historian. Maternal Grandmother: Atrial Fibrillation
Maternal Grandfather: HTN
Paternal Grandmother: None
Paternal Grandfather: None
3 Siblings: None
Personal/Social Hx:
Chief Complaint/RFE: L.G. is an active child, involved in Girl Scouts, softball, dance, and track.
LG states “my right ear hurts.” She is starting 3rd grade in the fall. Reports doing well in school and having
lots of friends. She lives with her mom, dad, and two siblings at home. Her
mother is a special education teacher, and her father works for the school
district with IT. Reports no exposure to smoke or other environmental irri-
Hx Present Illness: (7 Variables but do not list as such) tants. She has good support from her family and friends.
L.G. is an 8-year-old Hispanic female who returned from a weeklong Girl Scout camp. She reports that her right ear started hurting on the
bus on the way home last night. She describes the pain as aching, particularly on the outside of her ear, which made it uncomfortable to wear
headphones. She denies any fever during the camp but mentions that it was really hot throughout the week. She also states that she did a lot
of swimming at camp and may have gotten some water in her ear. L.G. rates the pain as 7/10 in severity, and that the pain has been constant
since it started. She denies any discharge from the ear, hearing loss, ringing, or recent trauma to the ear. There has been no history of ear
infections. The pain worsens when she touches or puts pressure on the outer part of her ear. Reports no alleviating factors.
CURRENT HEALTH
Medications: No prescription or OTC medications. Reports taking 2 multivitamin gummies, attempts to take daily, but states she only takes
it when she remembers to.
Allergies: No known drug, food, seasonal, environmental, or latex allergies.
Last PE & Screenings: Mother reports last physical exam was in June 2024, in which she had a vision and hearing screening, and last dental
visit was in June 2024. All expected findings, nothing abnormal reported.
Immunization Status: Mother reports L.G. being up to date on her childhood vaccinations including Tdap, MMR, and Varicella. Denies
receiving last year’s flu vaccine, last flu vaccine was in the fall of 2022.
LMP & Birth Control (if applicable) Not applicable.
PMH
Illnesses & Trauma: L.G. is generally healthy with no significant medical history. No history of ear infections or chronic illnesses per
mother. Denies any recent trauma or injuries.
Hospitalizations/Surgeries: Reports no history of hospitalizations or surgeries.
OB Hx/Sexual Hx: L.G. was born at 39 weeks, vaginal birth, and was 6 lbs. 9 oz. No complications at birth reported by mother. Achieved
developmental milestones at appropriate age. Denies any sexual history.
Emotional/Psy Hx: Reports feeling frustrated with ear pain. Denies any feelings of sadness. Mother denies any history of psychiatric
conditions.
REVIEW OF SYSTEMS
General: Pt has not had fever, no recent weight change. Pt denies any recent illness.
Nutrition: Denies decrease in appetite. States she “eats whatever I want” and has no dietary restrictions. Reports eating 3 meals a day.
Skin/Hair/Nails: Denies any rash, swelling, or redness around the ear.
NAME:
College of Nursing and Health Innovation, University of Texas at Arlington
NURS 5130: Pediatric Health Assessment Lab
Courtney Shea Werner APRN, MSN, CPNP
July 16, 2025
, SOAP Note Form
S/ Identifying Information: (initials, age/DOB, gender, Family Hx:
reliability)
L.G., 8 year-old, Female, Presenting with mother, Reliable Mother and Father: None
historian. Maternal Grandmother: Atrial Fibrillation
Maternal Grandfather: HTN
Paternal Grandmother: None
Paternal Grandfather: None
3 Siblings: None
Personal/Social Hx:
Chief Complaint/RFE: L.G. is an active child, involved in Girl Scouts, softball, dance, and track.
LG states “my right ear hurts.” She is starting 3rd grade in the fall. Reports doing well in school and having
lots of friends. She lives with her mom, dad, and two siblings at home. Her
mother is a special education teacher, and her father works for the school
district with IT. Reports no exposure to smoke or other environmental irri-
Hx Present Illness: (7 Variables but do not list as such) tants. She has good support from her family and friends.
L.G. is an 8-year-old Hispanic female who returned from a weeklong Girl Scout camp. She reports that her right ear started hurting on the
bus on the way home last night. She describes the pain as aching, particularly on the outside of her ear, which made it uncomfortable to wear
headphones. She denies any fever during the camp but mentions that it was really hot throughout the week. She also states that she did a lot
of swimming at camp and may have gotten some water in her ear. L.G. rates the pain as 7/10 in severity, and that the pain has been constant
since it started. She denies any discharge from the ear, hearing loss, ringing, or recent trauma to the ear. There has been no history of ear
infections. The pain worsens when she touches or puts pressure on the outer part of her ear. Reports no alleviating factors.
CURRENT HEALTH
Medications: No prescription or OTC medications. Reports taking 2 multivitamin gummies, attempts to take daily, but states she only takes
it when she remembers to.
Allergies: No known drug, food, seasonal, environmental, or latex allergies.
Last PE & Screenings: Mother reports last physical exam was in June 2024, in which she had a vision and hearing screening, and last dental
visit was in June 2024. All expected findings, nothing abnormal reported.
Immunization Status: Mother reports L.G. being up to date on her childhood vaccinations including Tdap, MMR, and Varicella. Denies
receiving last year’s flu vaccine, last flu vaccine was in the fall of 2022.
LMP & Birth Control (if applicable) Not applicable.
PMH
Illnesses & Trauma: L.G. is generally healthy with no significant medical history. No history of ear infections or chronic illnesses per
mother. Denies any recent trauma or injuries.
Hospitalizations/Surgeries: Reports no history of hospitalizations or surgeries.
OB Hx/Sexual Hx: L.G. was born at 39 weeks, vaginal birth, and was 6 lbs. 9 oz. No complications at birth reported by mother. Achieved
developmental milestones at appropriate age. Denies any sexual history.
Emotional/Psy Hx: Reports feeling frustrated with ear pain. Denies any feelings of sadness. Mother denies any history of psychiatric
conditions.
REVIEW OF SYSTEMS
General: Pt has not had fever, no recent weight change. Pt denies any recent illness.
Nutrition: Denies decrease in appetite. States she “eats whatever I want” and has no dietary restrictions. Reports eating 3 meals a day.
Skin/Hair/Nails: Denies any rash, swelling, or redness around the ear.
