NSG 6435 WEEK 10: PEDIATRIC SOAP NOTE
Name: SW Date: 8/14/19
Sex: Female Age/DOB/Place of Birth: 15 yr/7-1-2004/Washington, NC
SUBJECTIVE
Historian: Patient
Present Concerns/CC: “I’ve been really anxious for about a year now.”
Child Profile: Pt is a healthy appearing 15-year-old Caucasian female. Patient states her overall health was good
up until the past year when her anxiety set in. Pt has since stopped attending high school and is being home
schooled. She reports no chronic illnesses, no speech or growth delays. She denies any previous injuries that have
required medical attention. She states she eats well most of the time and drinks water often. She states she has a
good support system with her family but has lost many friends since she stopped attending public school.
HPI: 15-year old female presents to clinic c/o anxiety for the past year. Mother is present at clinic but only in exam
room for part of the visit. Patient states she is not sure what triggered the anxiety, it started slowly and has
progressed to the point that she is being home schooled because attending public school was too stressful for her. Pt
c/o periods of palpitations, SOB, dizziness, and diarrhea. Pt denies any traumatic events that she is aware of that
could have caused the anxiety. Patient has no previous medical history requiring treatment or chronic care. Pt has
not attempted to treat the anxiety with medications, she has however tried meditating and deep breathing exercises
when the anxiety
Medications: is severe.
None
PMH: Pt was born during cesarean section at 39 weeks gestation. Mother denies problems during pregnancy or
delivery, states she had cesarean section with this pregnancy because she had one with her first pregnancy.
Allergies: NKA
Medication Intolerances: None
Hospitalizations/Surgeries: No surgical history or hospitalizations reported.
Immunizations: Up to date
Family History
Mother, 50, Healthy
Father, 49, Healthy
Brother, 20, Healthy
, NSG 6435 WEEK 10: PEDIATRIC SOAP NOTE
Social History
Pt currently lives at home with her mother and father. Brother is away at college. Pt is home schooled by
mother. Pt denies alcohol, tobacco, or illicit drug use.
ROS
General Cardiovascular
Pt states she is in good physical health, denies any C/o palpitations and dizziness at times. Denies any previous
recent illnesses. Pt does c/o heart conditions, chest pain, or chest pressure.
Skin Respiratory
Denies skin lesions, rashes, or issues with fingernails C/o SOB at times. Denies respiratory infections, breathing
or hair growth. difficulties, or coughing.
Eyes Gastrointestinal
Denies eye pain, blurry vision, or redness. C/o diarrhea at times. Denies any nausea, vomiting,
abdominal pain, blood in stools, constipation, bloating, or
tarry stools.
Ears Genitourinary/Gynecological
Denies ear pain, hearing loss, or drainage. Denies urinary urgency, frequency burning, or change in
color of urine.
Nose/Mouth/Throat Musculoskeletal
Denies drooling, bleeding gums, nasal discharge, or Denies history of broken bones, no muscle or joint pain.
nasal obstructions.
Breast Neurological
Denies any masses, lesions, or lumps. Denies syncope, seizures, transient paralysis, weakness,
paresthesia’s, black out spells. No tics or tremors,
headaches or black out spells.
Heme/Lymph/Endo Psychiatric
Denies blood transfusions or bleeding disorders. No C/o anxiety for the past year. Denies severe depression or
growth problems. No endocrine disorders. suicidal ideations.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 126 BMI: 15.7 Temp 98.2 BP 108/68
Height 66 inches Pulse 88 Resp 14
Name: SW Date: 8/14/19
Sex: Female Age/DOB/Place of Birth: 15 yr/7-1-2004/Washington, NC
SUBJECTIVE
Historian: Patient
Present Concerns/CC: “I’ve been really anxious for about a year now.”
Child Profile: Pt is a healthy appearing 15-year-old Caucasian female. Patient states her overall health was good
up until the past year when her anxiety set in. Pt has since stopped attending high school and is being home
schooled. She reports no chronic illnesses, no speech or growth delays. She denies any previous injuries that have
required medical attention. She states she eats well most of the time and drinks water often. She states she has a
good support system with her family but has lost many friends since she stopped attending public school.
HPI: 15-year old female presents to clinic c/o anxiety for the past year. Mother is present at clinic but only in exam
room for part of the visit. Patient states she is not sure what triggered the anxiety, it started slowly and has
progressed to the point that she is being home schooled because attending public school was too stressful for her. Pt
c/o periods of palpitations, SOB, dizziness, and diarrhea. Pt denies any traumatic events that she is aware of that
could have caused the anxiety. Patient has no previous medical history requiring treatment or chronic care. Pt has
not attempted to treat the anxiety with medications, she has however tried meditating and deep breathing exercises
when the anxiety
Medications: is severe.
None
PMH: Pt was born during cesarean section at 39 weeks gestation. Mother denies problems during pregnancy or
delivery, states she had cesarean section with this pregnancy because she had one with her first pregnancy.
Allergies: NKA
Medication Intolerances: None
Hospitalizations/Surgeries: No surgical history or hospitalizations reported.
Immunizations: Up to date
Family History
Mother, 50, Healthy
Father, 49, Healthy
Brother, 20, Healthy
, NSG 6435 WEEK 10: PEDIATRIC SOAP NOTE
Social History
Pt currently lives at home with her mother and father. Brother is away at college. Pt is home schooled by
mother. Pt denies alcohol, tobacco, or illicit drug use.
ROS
General Cardiovascular
Pt states she is in good physical health, denies any C/o palpitations and dizziness at times. Denies any previous
recent illnesses. Pt does c/o heart conditions, chest pain, or chest pressure.
Skin Respiratory
Denies skin lesions, rashes, or issues with fingernails C/o SOB at times. Denies respiratory infections, breathing
or hair growth. difficulties, or coughing.
Eyes Gastrointestinal
Denies eye pain, blurry vision, or redness. C/o diarrhea at times. Denies any nausea, vomiting,
abdominal pain, blood in stools, constipation, bloating, or
tarry stools.
Ears Genitourinary/Gynecological
Denies ear pain, hearing loss, or drainage. Denies urinary urgency, frequency burning, or change in
color of urine.
Nose/Mouth/Throat Musculoskeletal
Denies drooling, bleeding gums, nasal discharge, or Denies history of broken bones, no muscle or joint pain.
nasal obstructions.
Breast Neurological
Denies any masses, lesions, or lumps. Denies syncope, seizures, transient paralysis, weakness,
paresthesia’s, black out spells. No tics or tremors,
headaches or black out spells.
Heme/Lymph/Endo Psychiatric
Denies blood transfusions or bleeding disorders. No C/o anxiety for the past year. Denies severe depression or
growth problems. No endocrine disorders. suicidal ideations.
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 126 BMI: 15.7 Temp 98.2 BP 108/68
Height 66 inches Pulse 88 Resp 14
