NSG 6435 WEEK 4: PEDIATRIC SOAP NOTE
Name: RO Date: 7/3/19
Sex: Female Age/DOB/Place of Birth: 2/3-20-2017/Washington NC
SUBJECTIVE
Historian: Mother
Present Concerns/CC:
“She’s had a fever and a sore throat for 2 days. She’s also been stopped up and coughing a lot.”
Child Profile:
Child participates in dressing and undressing herself, bathing, and brushing her teeth. Child
has met all developmental milestones appropriate for 20-month-old, including: fine motor
skills, such as drinking from a cup with little spilling, removing socks, and stacking four to
six blocks; and gross motor skills, such as throwing objects while aiming, walking well
independently, and pushing and pulling toys.
HPI:
2-year-old female pt presents to the clinic with her mother who complains of pt having fever, sore throat, congestion,
and cough x 2 days. Mother states pt normally sleeps well and seldom cries, however she has been crying consistently
for the past 2 days and has barely slept the past 2 nights. Mother states eating and drinking makes pt’s sore throat worse.
Tylenol seems to help with the pain and fever. Symptoms seem to be worse in the morning and at night, and they are bad
enough that they disrupt normal activities per mother.
Medications:
Tylenol 5 ml every 4-6 hours as needed for pain and fever, not to exceed 5 doses in 24 hours
PMH: Pt was born during vaginal birth at 39-week gestation, no complications during birth or pregnancy. Pt was
breastfed for 12 months.
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major
traumas: None
Hospitalizations/Surgeries:
None
Immunizations: Up to date
Family History
Mother, 22, Healthy
Father, 24, Healthy
Sister, 2 months, Healthy
, NSG 6435 WEEK 4: PEDIATRIC SOAP NOTE
Social History
Pt currently living with married parents and baby sister. Neither parent graduated high school. Dad works for local
fishery company, mother is stay at home mom. Mother denies ETOH, tobacco, or illicit drug use for herself and for
her husband.
ROS
General Cardiovascular
Mother states pt has been fussy, stopped up, Mother denies any shortness of breath displayed with
coughing, c/o sore throat, and running fever x 2 days activities, no signs of chest pain noted
Skin Respiratory
Mother denies any skin abnormalities such as rashes, Mother c/o pt coughing, denies any shortness of breath,
abnormal moles, or dry skin. congestion
Name: RO Date: 7/3/19
Sex: Female Age/DOB/Place of Birth: 2/3-20-2017/Washington NC
SUBJECTIVE
Historian: Mother
Present Concerns/CC:
“She’s had a fever and a sore throat for 2 days. She’s also been stopped up and coughing a lot.”
Child Profile:
Child participates in dressing and undressing herself, bathing, and brushing her teeth. Child
has met all developmental milestones appropriate for 20-month-old, including: fine motor
skills, such as drinking from a cup with little spilling, removing socks, and stacking four to
six blocks; and gross motor skills, such as throwing objects while aiming, walking well
independently, and pushing and pulling toys.
HPI:
2-year-old female pt presents to the clinic with her mother who complains of pt having fever, sore throat, congestion,
and cough x 2 days. Mother states pt normally sleeps well and seldom cries, however she has been crying consistently
for the past 2 days and has barely slept the past 2 nights. Mother states eating and drinking makes pt’s sore throat worse.
Tylenol seems to help with the pain and fever. Symptoms seem to be worse in the morning and at night, and they are bad
enough that they disrupt normal activities per mother.
Medications:
Tylenol 5 ml every 4-6 hours as needed for pain and fever, not to exceed 5 doses in 24 hours
PMH: Pt was born during vaginal birth at 39-week gestation, no complications during birth or pregnancy. Pt was
breastfed for 12 months.
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major
traumas: None
Hospitalizations/Surgeries:
None
Immunizations: Up to date
Family History
Mother, 22, Healthy
Father, 24, Healthy
Sister, 2 months, Healthy
, NSG 6435 WEEK 4: PEDIATRIC SOAP NOTE
Social History
Pt currently living with married parents and baby sister. Neither parent graduated high school. Dad works for local
fishery company, mother is stay at home mom. Mother denies ETOH, tobacco, or illicit drug use for herself and for
her husband.
ROS
General Cardiovascular
Mother states pt has been fussy, stopped up, Mother denies any shortness of breath displayed with
coughing, c/o sore throat, and running fever x 2 days activities, no signs of chest pain noted
Skin Respiratory
Mother denies any skin abnormalities such as rashes, Mother c/o pt coughing, denies any shortness of breath,
abnormal moles, or dry skin. congestion
