Peds OM - soap note PDF

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SOAP Note Peds OM Visit Chief Complaint: Patient’s mother states that she “thinks he has an ear infection.” History of Present Illness: J.S. is a 20 month old healthy appearing Hispanice male who presented to the clinic for a possible ear infection. He resides with his grandparents, mom, and big sister. Per the patient’s mother, he has been pulling at his left ear and running a low grade temperature (99.6F-100F) for around 2 days. The patient has been very irritable and somewhat fussy as well. She said that she gives him liquid Tylenol in order to help with the pain and break his fever, with this working for around 6 hours before she has to give him more. Developmental Growth As per mom, he recognizes names of familiar people, objects, and body parts, he follows simple instructions, he like to scribbles in a paper sheet and kicks a balls. During the interview, he walks alone, climbs onto and down from furniture unassisted, he was able to points to object or picture when it’s named for him, stands on tiptoe and Uses two- to four-word sentences Past Medical History: J.S. has had no major illness to date. She has no history of major problems. Her history does include: Immunizations up to date for age: o Hep B series o DTaP: 1st, 2nd, and 3rd dose o IPV: 1st, 2nd, and 3rd o MMR: 1st dose o VAR: 1st dose o Hep A series Surgical History: Denies surgical history per mom Allergies: No Known Allergies Medications: None Family History: Mother, 31yo - HTN Father, 31yo – asthma Sister, 6yo - asthma Grandfather, deceased 72 yo - MI Grandmother, 82 yo – cataracts, HTN Social History:

Resides in a 2nd floor apartment with her boyfriend and daughter, mother reports a good support system. Mom smokes cigarettes in the home and socially drinks alcohol; denies illegal drug use. J.S. attends daycare Monday through Friday. Sits in a 5-point harness car seat with latch system Review of Systems: General: Irritable and crying more than usual, low grade temp; denies weight loss, fever, night sweats, fatigue, and chills HEENT: Guarding and pulling at left ear, teething; Denies difficulty hearing, runny nose, mouth sores, and sore throat RESP: Denies cough, sputum, wheezing, and dyspnea CV: Denies cyanosis, swelling, erythema of skin GI: Denies constipation, abdominal pain, nausea, vomiting and diarrhea GU: Currently potty training during the day and diapers at bedtime; denies difficulty urinating MS: Denies recent trauma and falls SKIN: Denies rash, lesion, or color changes NEURO: Denies difficulty speaking and loss of consciousness PSYCH: Denies difficulty sleeping, behavioral changes, concerns for growth/development, and hyperactivity Physical Exam: Vitals: T 101.2F (38.4C) oral | Pulse 110, regular| Resp 30 | BP 98/65 | Wt 28lbs (12.7 kg) | Ht: 33.2in | SpO2 98% | BMI 18.1 kg/m2 GENERAL: Sitting on mom’s lap, was seen walking in room upon my entrance. Appears to be irritable and cries intermittently. Patient noted to be guarding his left ear HEAD: Normocephalic, fontanels are closed, suture lines intact, hair evenly distributed EYES: PERRLA, sclera white, conjunctiva pink, extra ocular movements intact; no hemorrhage or exudate noted EARS: External appearance normal-no lesions, redness, or swelling; on otoscopic exam tympanic membranes and inner ear are red, fluid is also noted behind the tympanic membrane. Hearing is intact. NOSE: Nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge NECK: Neck symmetrical, supple, full ROM, non-tender without masses THROAT/MOUTH: Oral mucosa pink and moist; teething w/ 8 teeth noted; pharynx w/o erythema, exudates, or lesions. LUNGS: Even and unlabored, bilaterally clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds CV: Regular rate and rhythm, normal sinus rhythm with S1, S2 normal; no murmur, clicks, rubs, or gallop GI: Positive bowel sounds in all four quadrants. Soft, non-distended, non-tender; no guarding, rebound, or masses noted GU: No bladder distention. Two testes palpated. No redness or diaper rash noted. SKIN: Warm, dry, and intact, capillary refill < 3sec.; no rash, lesion, pallor or cyanosis noted MS: Full range of motion in all four extremities, grossly normal function and strength of

extremities. No bone, joint, or muscle tenderness or swelling. NEURO: Speech clear. Posture erect. Balance stable; gait normal. Symmetric movements, reflexes grossly intact, no focal deficits. PSYCH: Mood and affect appropriate. Irritable during exam and comforted by mom. Growth Chart/Developmental Assessment Tool: Completed on last visit an 18-month ASQ: Results: Development is on schedule; no further action taken at this time Lab Data/Tests: (last visit at 18 months) H/H - 11.4/34.3 (9.9-17.3)/(29-44) Lead -...