NR509_SOAP_Note_Pediatric week 6

Document Content and Description Below

hospitalizations, and surgeries. Depending on the CC, more info may be needed. Pneumonia 1 year ago-unsure of medication given Recurrent ear infections at younger age Frequent colds Frequent nasal... drainage No surgical history No prior hospitalizations Up to date on childhood immunizations Not up to date on flu vaccination Attends biannual primary care visits- Last physical: 2 months ago Attends yearly dental exams No history of eye exams Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Lives at home with mother, father, grandmother and grandfather Household uses English primarily as language; Secondary: Spanish Father smokes cigars on occasion in the household Student in the 3rd grade Enjoys English and computers Hobbies: playing video games, writing stories Exercise: Gym class daily, going to park with friends after school and on weekends when nice out Wants to be a director when he is older with his friend Tony, who will be an actor Fears: Bad guys in movies Diet: Dislikes veggies; drinks 7-8 glasses of water a day; Breakfast: cereal, fruit, waffles, eggs, bacon Lunch: sandwich, chips, applesauce, pudding Dinner: chicken, rice, ham, stew Bowel Regimen: 1-2 bowel movements daily Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. [Show More]

Last updated: 1 year ago

Preview 1 out of  pages