PEDIATRIC FILLABLE SOAP NOTE
TEMPLATE
STUDENT NAME: Barbra Caldwell
Patient Initials: T. A.
DATE OF ASSIGNMENT: 05/11/2019
Date of Encounter: 05/11/2019
Sex: Male Age/DOB/Place of Birth: 2y 2 mo/8-01-2013
SUBJECTIVE
Historian: Mother
Present Concerns/CC: “stomach hurts and he just isn’t himself”
Child Profile: 26-month-old male that is ill appearing with a history of down syndrome. Mom states child is normally active and
healthy; however, he does not talk much due to delays caused by down syndrome. Mom states child is clumsy but has not had
any serious injuries in the past. He is a good eater and sleeps all night.
HPI: 26-month-old male presents to ER with mother with complaints of abdominal pain after falling out of
bed at nap time x2 days ago. Has decrease in appetite and has had x one vomiting episode that started after
falling from bed. Child is lethargic, tachypneic, has decreased urine output, and is borderline hypotensive. On
exam a bruise is noted on abdomen, abdomen is distended, and has diffused tenderness with guarding and
rebound tenderness and is having dark colored urine. Child has down syndrome with developmental delays
and is status-post surgical repair of atrial-septal defect. Mom states that her boyfriend was watching child
when incident occurred.
Medications: None
1|PEDIATRICSOAPNOTE
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, PEDIATRIC FILLABLE SOAP NOTE
TEMPLATE
PMH: No complications with pregnancy or
delivery Allergies: None
Medication Intolerances: None
Chronic Illnesses/Major traumas: Atrioventricular septal defect, heart murmur, transient CHF
Hospitalizations/Surgeries: Atrioventricular septal defect repair
Immunizations: DTaP x 5, Hep A x2, Hep B x 3, HIB x 4, MMR x 2, PCV 7 x 4, IPV x 4, Varicella x 2, flu x 2
Family History: Mother-Anemia, Father-unknown, 5-yr-old sibling-asthma, 6-mo-old sibling-healthy
Social History: Mom is a single high school graduate that works as a cashier. Mom can not afford daycare;
therefore, she relies on her neighbors and her boyfriend for childcare. Mom tries to limit using boyfriend as the
kids get on his nerves sometimes. Mother and boyfriend smoke in the house; however, they try to smoke in a
different room or away from the kids. Mom denies any ETOH or drug use and states she feels safe in their home
and community.
Review of Systems (ROS)
General: Mother denies fevers, insomnia, change in Cardiovascular: status-post surgical repair of atrial-
weight, or recent illness. Reports child is lethargic, septal defect. Denies chest pain, palpations, or cold
dehydrated and has a poor appetite and not drinking fingers.
fluids.
Skin: Large gruise on abdomen x 2 days. States skin Respiratory: No SOB, coughing, or wheezing. Mom
is pale and clammy. states child is breathing faster than normal.
2|PEDIATRICSOAPNOTE
This study source was downloaded by 100000852681095 from CourseHero.com on 12-01-2022 23:29:12 GMT -
https://www.coursehero.com/file/42123781/wk-7-soap-note-
TEMPLATE
STUDENT NAME: Barbra Caldwell
Patient Initials: T. A.
DATE OF ASSIGNMENT: 05/11/2019
Date of Encounter: 05/11/2019
Sex: Male Age/DOB/Place of Birth: 2y 2 mo/8-01-2013
SUBJECTIVE
Historian: Mother
Present Concerns/CC: “stomach hurts and he just isn’t himself”
Child Profile: 26-month-old male that is ill appearing with a history of down syndrome. Mom states child is normally active and
healthy; however, he does not talk much due to delays caused by down syndrome. Mom states child is clumsy but has not had
any serious injuries in the past. He is a good eater and sleeps all night.
HPI: 26-month-old male presents to ER with mother with complaints of abdominal pain after falling out of
bed at nap time x2 days ago. Has decrease in appetite and has had x one vomiting episode that started after
falling from bed. Child is lethargic, tachypneic, has decreased urine output, and is borderline hypotensive. On
exam a bruise is noted on abdomen, abdomen is distended, and has diffused tenderness with guarding and
rebound tenderness and is having dark colored urine. Child has down syndrome with developmental delays
and is status-post surgical repair of atrial-septal defect. Mom states that her boyfriend was watching child
when incident occurred.
Medications: None
1|PEDIATRICSOAPNOTE
This study source was downloaded by 100000852681095 from CourseHero.com on 12-01-2022 23:29:12 GMT -
https://www.coursehero.com/file/42123781/wk-7-soap-note-
, PEDIATRIC FILLABLE SOAP NOTE
TEMPLATE
PMH: No complications with pregnancy or
delivery Allergies: None
Medication Intolerances: None
Chronic Illnesses/Major traumas: Atrioventricular septal defect, heart murmur, transient CHF
Hospitalizations/Surgeries: Atrioventricular septal defect repair
Immunizations: DTaP x 5, Hep A x2, Hep B x 3, HIB x 4, MMR x 2, PCV 7 x 4, IPV x 4, Varicella x 2, flu x 2
Family History: Mother-Anemia, Father-unknown, 5-yr-old sibling-asthma, 6-mo-old sibling-healthy
Social History: Mom is a single high school graduate that works as a cashier. Mom can not afford daycare;
therefore, she relies on her neighbors and her boyfriend for childcare. Mom tries to limit using boyfriend as the
kids get on his nerves sometimes. Mother and boyfriend smoke in the house; however, they try to smoke in a
different room or away from the kids. Mom denies any ETOH or drug use and states she feels safe in their home
and community.
Review of Systems (ROS)
General: Mother denies fevers, insomnia, change in Cardiovascular: status-post surgical repair of atrial-
weight, or recent illness. Reports child is lethargic, septal defect. Denies chest pain, palpations, or cold
dehydrated and has a poor appetite and not drinking fingers.
fluids.
Skin: Large gruise on abdomen x 2 days. States skin Respiratory: No SOB, coughing, or wheezing. Mom
is pale and clammy. states child is breathing faster than normal.
2|PEDIATRICSOAPNOTE
This study source was downloaded by 100000852681095 from CourseHero.com on 12-01-2022 23:29:12 GMT -
https://www.coursehero.com/file/42123781/wk-7-soap-note-
