South University - NSG 64355 Week 8:Pediatric SOAP Note: Complete Version.

NP Student Name: Skye Acho Child’s Initials: TA DOB: 2/05/20017 Clinical Date: 6/15/19 Age: 24 months old Place of Born: Week Soap Project: W1 W3 W7 W8 Sex: M _X__ F ___ Type of Soap Note: Well child visit ___ ...

NP Student Name: Skye Acho Child’s Initials: TA DOB: 2/05/20017 Clinical Date: 6/15/19 Age: 24 months old Place of Born: Week Soap Project: W1 W3 W7 W8 Sex: M _X__ F ___ Type of Soap Note: Well child visit ____ Sick visit __X__ SUBJECTIVE Historian: Patient’s mother Present Concerns/CC: “abdominal pain x2 days” Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living (age appropriate): Patient’s mother states that TA is well-behaved, has good appetite, drinks adequate amount of fluid, sleeps well during night. Safety Practices: Child sits in the back seat with a forward-facing car seat. Neighborhood is considered generally safe. Changes in daycare/school/after-school care: Pt mother states unable to afford day care and neighbors or mother’s boyfriend babysit the children. Sports/physical activity: Mother states “normally T.A. is a very active and playful toddler” Developmental History: Mother states that he is developmentally delayed due to the patient having Down Syndrome. Mother states he does not speak that much and does not pick things up as quickly. In addition, patient does fall and trip often, and bumps into things but this is the first time the patient is requiring medication attention. HPI: Tommy, a 26-month-old male with Down Syndrome, was brought into the ED by his mother who reports he has been “complaining” of abdominal pain x 2 days, had emesis x 1, is lethargic, sweating, breathing rapidly and has diminished urine output. All symptoms started soon after his “falling out of the bed during his nap.” She denies associated head trauma but claims he is not eating or drinking. She denies prior injuries that required medical attention. PMH is notable for post atrial-septal defect repair with transient CHF as an infant. The child appears listless and pale. Exam reveals hypotension, tachycardia, tachypnea, and signs of dehydration. The abdomen is grossly distended with significant epigastric bruising, in a distribution that is atypical for a fall. It is firm to palpation with diffuse tenderness, guarding, and rebound tenderness. A reducible 2.0cm-umbilical hernia is present. Medications: Patient is not on any medications. (Med, dosage, & reason for med) PMH: Allergies: None Chronic Illnesses/Major traumas: AV septal defect, transient CHF, heart murmu Hospitalizations/Surgeries: AV septal defect repair Immunizations: Up-to-date Family Medical History: Mother has a history of anemia. Unknown medical history of father, father is not currently involved. Patient has 5 year old sibling with asthma, and, a 6 month years old, in good health. Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Current living situation/partner/marital status: Pt mother is a single-mother but is in a relationship with 6-month-old siblings father. Mother currently employed, but states she is unable to afford daycare. Neighbors and mother boyfriend babysit children. Pt mother states boyfriend does not like to babysit because the kids whine at times, and he can’t tolerate it. Educational level (as appropriate): Pts mother graduated high school Occupational history (as appropriate): Mother currently employed, but states she is unable to afford daycare. Substance use/abuse (ETOH, tobacco, and marijuana): Mother denies substance, ETOH, or marijuana use for both her and the father. Mother and boyfriend both smoke. Pt is exposed to second hand smoking Firearms in home: No firearms in the house per mother Safety status: Pt mother feels safe in community and surrounding neighborhood and has adequate transportation and access to care. References Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2016). Pediatric primary care: A handbook for nurse practitioners, (6th ed.). Philadelphia: Saunders. Khan, S. (2012). Functional Abdominal Pain in Children. Retrieved from http://patients.gi.org/topics/functional-abdominal-pain-in-children/