NP Student Name: Rebecca Wood Child’s Initials: TA DOB: 04/09/2017
Clinical Date: 6/15/19 Age: 26 months Place of Born: “here”
Week Soap Project: W7 Sex:
M _x__
F ___ Type of Soap Note:
Well child visit ____
Sick
...
NP Student Name: Rebecca Wood Child’s Initials: TA DOB: 04/09/2017
Clinical Date: 6/15/19 Age: 26 months Place of Born: “here”
Week Soap Project: W7 Sex:
M _x__
F ___ Type of Soap Note:
Well child visit ____
Sick visit __x__
SUBJECTIVE
Historian: Mother
Present Concerns/CC: Mother states “Tommy isn’t himself”
Child Profile:
Activities of Daily Living (age appropriate): Mother helps child with ADLs
Safety Practices: Patient sits in car seat and mother denies access to guns.
Changes in daycare/school/after-school care: Does not attend daycare
Developmental History: Mother reports the child is not hitting developmental milestones because of his down syndrome. Child does not say many words.
HPI: 26-month-old male brought to the ED by his mother who states he has been complaining of abdominal pain for 2 days, vomited, is lethargic, diaphoretic, tachypneic, and has decreased urine output. Mother reports these symptoms started shortly after “falling out of bed.” Mother denies head trauma. Mother denies history of similar symptoms requiring medical attention.
Medications: None
PMH:
Allergies: NKDA
Chronic Illnesses/Major traumas: Down Syndrome
Hospitalizations/Surgeries: Atrial septal defect repair
Family Medical History Mother has anemia, father has no known history, one older sibling has asthma
Social History
Current living situation/partner/marital status: Mother, mother’s boyfriend, and 2 siblings
Firearms in home: Mother denies guns in the home
Safety status: Mother reports the child rides in a car seat and feels safe in the community
Chiocca, E. M., (2015). Advanced Pediatric Assessment (set ebook; 2nd ed.). Springer Publishing. ISBN:
9780826128683
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medical information in child abuse investigations. Child Abuse & Neglect, 92, 167–178.
https://doi.org/10.1016/j.chiabu.2019.02.012
Liu, B. C. C., & Vaughn, M. S. (2019). Legal and policy issues from the United States and internationally about
mandatory reporting of child abuse. International Journal of Law and Psychiatry, 64, 219–229.
https://doi.org/10.1016/j.ijlp.2019.03.007
Karmazyn, B., Duhn, R., Jennings, S., Wanner, M., Tahir, B., Hibbard, R., … Wanner, M. R. (2012). Long bone fracture
detection in suspected child abuse: contribution of lateral views. Pediatric Radiology, 42(4), 463–469.
https://doi.org/10.1007/s00247-011-2248-3
Palusci, V. J. (2017). Child Abuse : Children with Disabilities. Hauppauge, New York: Nova Science Publishers, Inc.
Retrieved from https://search-ebscohost-com.southuniversity.l ibproxy.edmc.edu/login.aspx?direct=true &db=nlebk&AN=1562829&site=eds-live
Turner, R. A., & Rogers, H. O. (2012). Child Abuse : Indicators, Psychological Impact and Prevention. New York: Nova
Science Publishers, Inc. Retrieved from https://search-ebscohost
-com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=nlebk&AN=541949&site=eds-live
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