Exam (elaborations)
NSG 6435 Comprehensive SOAP Note Tommy Acker V5
- Course
- Institution
NSG 6435 Comprehensive SOAP Note Tommy Acker V5
[Show more]
Seller
Follow
FLOYYD
Reviews received
Content preview
Pediatric SOAP noteName: TA Date: 12/06/19
Sex:
DOB- DOB: 08.01.17 AGE-26 Months old.
Male
SUBJECTIVE
Historian: Patient’ mother
Present Concerns/CC: "Tommy is not himself" my child has been whining and refusing to eat. He
seems. When I looked on his tummy, I found a big bruise”
Child Profile:
Sexual history- Mom denies sexual abuse
ADLs- Some developmental delay, but able to eat finger foods, drink from a sipping cup
Safety- No exposure to second-hand smoke, guns or chemicals. Uses car seat and helmet when riding
Milestone-Physical and developmental delay in conjunction with down syndrome
HPI:
26 months male here with his mother complaining of abdominal pain, irritability, reduced appetite, dark
and reduced urinary output, nausea and vomiting that has been ongoing for two days. Mom stated
symptoms started since patient fell from his 3 feet crib. Other acute symptoms noted are tachypnea,
hypotension and tachycardia. Denied any trauma to head, diarrhea and difficulty breathing.
Medications
No home medications
, Pediatric SOAP note
PMH:
Allergies: NKDA
Chronic Illnesses/Major
ASD
Traumas:
Post fall
Hospitalization/ Surgical
ASD Repair
Immunizations:
Up to date
Family/Medical History
TA who has down syndrome lives with his mother, and his two other siblings. TA had atrial septic defect
as a baby and has since been repaired. His mother is anemic. His 5-year-old brother is asthmatic. No
known medical on his 6 months old brother. No know medical history on his father. His mother, a high
school graduate works a cashier.
Social History
TA is surrounded by his family, mother’s boyfriend and neighbors. Usually termed “happy and clumsy
baby” by mom.
ROS
General Cardiovascular
Admits to low energy, no appetite and Admits to repaired ASD, heart murmur and
irritability. Denies weight loss heart failure. Denies chest pain, palpitations,
PND, orthopnea, or swelling to body parts.
Skin Respiratory
Admits to easily bruise. Old scare to chest Denies any pulmonary trauma, SOB or difficulty
breathing.
Eyes Gastrointestinal
Denies trauma to eye. No tearing or difficulty Admits to abdominal pain that started 2 days post fall
with vision. from
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller FLOYYD. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79650 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now