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PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male
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| STUDENT NAME: Amy Brown | DATE OF ASSIGNMENT: 03/12/2019 |
| Patient Initials: M.L. | Date of Encounter: 03/07/2019 |
| Sex: Male | Age/DOB/Place of Birth: 7 year old male11/21/2011Cape Coral, FL |
| SUBJECTIVE | |
| Historian: Mother Present Concerns/CC: 7 year old Caucasian male accompanied by his mother with complaints of seeing lights and spacing out. The mother states that her son stares into space and she tries to snap him out of it and nothing works. Child Profile: Child attends public school and is doing well according to his mother. | |
| HPI: O: Child has been having episodes where he stares into space x6 months. L: There is no specific location as the child does not know it is happening D: Per the mother the episodes usually last 10-30 seconds C: No specific character, the child is non responsive A: Per the mother there does not seem to be any aggravating factors R: No relieving factors, the child eventually snaps out of it T: It does not occur at any specific time of the day S: The episodes do not vary in severity | |
| Medications: None | |
| PMH: The child has been diagnosed with mild ADHD and there has been question whether or not the patient is autistic. He is currently receiving behavioral therapy for the ADHD and his mother states that it seems to be working well. Allergies: None Medication Intolerances: None noted Chronic Illnesses/Major traumas: none Hospitalizations/Surgeries: none Immunizations: up to date |
| Eyes: No drainage from eyes. Denies any pain or itching to bilateral eyes. Patient does not use eye glasses. |
2|PEDIATRIC SOAP NOTE
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
| OBJECTIVE (plot height/weight/head circumference along with noting percentiles) PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male Attach growth chart | ||
| Weight: 34.47 kg | Temp 98.4 | BP 98/62 |
| Height 124.46 cm | Pulse 82 | Resp 22 |
| OBJECTIVE: Physical Examination reveals a well-nourished male, well developed for age. Temp: 98.4 HR 82, RR 22, O2 and blood pressure 98/62 Weight: 34.47kg, height 124.46 cm. Normal neurological exam performed in the office, no signs or symptoms of seizures. Child does not fall over during the episodes nor does he remember them. | ||
| General Appearance and parent–child interaction: Maternal/Child both appear well kept and are in clean clothing, interaction is normal, mother is very attentive to child needs. | ||
| Skin General skin overview reveals no significant rash or other lesion | ||
| HEENT Normocephalic, PERRL, Conjunctiva clear with no drainage noted. Tympanic membrane normal on right ear and bulging on left ear, no exudation noted in right but left with exudation in ear canal, nasal passages clear, no gross oropharyngeal lesions, oral mucosa wet, no adenopathy noted. | ||
| Cardiovascular regular rate, capillary refill < 3sec. No gallop or murmur noted. | ||
| Respiratory Breath sounds equal bilaterally. Equal chest rise and fall. | ||
| Gastrointestinal Bowel sounds heard in all four quadrants. Soft, no tenderness or distention noted upon palpation. Patient negative for rebound tenderness. Negative for Murphy’s sign, Rovsing’s sign or tenderness at McBurney’s point. | ||
| Breast Deferred PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male | ||
| Genitourinary: No dysuria, urinary frequency, or urgency; No evidence of UTI, hematuria, pelvic pain, bleeding, no vulvar itching, pain or rash. | ||
| Musculoskeletal: Musculoskeletal- Patient demonstrates full range of motion with no signs of pain. |
PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
| Neurological Alert and appropriate for age. No signs of focal motor or sensory deficit. Appropriate neurological exam for age. |
| Psychiatric Patient’s reactions are appropriate for age. |
| Pediatric/Adolescent Assessment Tools: Neurological assessment performed, all cranial nerves appear to be intact |
| ASSESSMENT (Diagnosis – 3 Differentials and Primary) Ø Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian maleØ Document Evidence based Rationale for ROS and each differential with pertinent positives and negativesØ Primary diagnosis ü Is #1 on list of differentialsü Evidence for primary diagnosis should be supported in the Subjective and Objective exams. |
| 1) Transient alteration of awareness IDC 10: R40.4 2) Seizure ICD-10: G40.9093) Autism ICD-10: F84.0 |
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| PLAN: Refer to neurology for further evaluation.Education: Have mother keep a journal of when episodes occur, what is going on around him and how long they last.True absence seizures (“petit mal”) are seizures that cannot be predictably interrupted by calling the child’s name or by tactile stimulation. It appears as if the person is having staring spells or behavioral lacity or basically “spacing out”. This condition is very common in children who have been previously diagnosed with attention deficit hyperactivity disorder (ADHD). When an absence seizure occurs it usually occurs during conversation or physical activity and looks as if they are daydreaming. PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male. These seizures usually happen multiple times a day (Wilfong, Nordli Jr, & Eichler, 2018).Follow up after he sees neurologist. If child has seizure prior to visit with neurology go to nearest emergency room. |
References
American Academy of Pediatrics. (2018). Screening tools. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx
Charles Y. Hu. (2019, February 27). MedCalc: Interactive Growth Charts: Front Page. Retrieved from http://www.medcalc.com/growth/?fbclid=IwAR33JR9Z91rWZrWzp0Xvals3w0S4MT-9ZzjmmHe2JpWNPt9sZUlUDleFS5Q
Chiocca, E., RNC, MSN, CPNP. Advanced Pediatric Assessment, Second Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826161765/
Wilfong, MD, A., Nordli Jr, MD, D., & Eichler, MD, MPH, A. (2018, September 23). Seizures and epilepsy in children: Classification, etiology, and clinical features. Retrieved from https://www.uptodate.com/contents/seizures-and-epilepsy-in-children-classification-etiology-and-clinical-features PEDIATRIC FILLABLE SOAP NOTE TEMPLATE – 7 year old Caucasian male
