South University - NSG 64355 Week 7:Pediatric SOAP Note: Complete Version.

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NP Student Name: Rebecca Wood Child’s Initials: TA DOB: 04/09/2017 Clinical Date: 6/15/19 Age: 26 months Place of Born: “here” Week Soap Project: W7 Sex: M _x__ F ___ Type of Soap Note: W... ell child visit ____ Sick visit __x__ SUBJECTIVE Historian: Mother Present Concerns/CC: Mother states “Tommy isn’t himself” Child Profile: Activities of Daily Living (age appropriate): Mother helps child with ADLs Safety Practices: Patient sits in car seat and mother denies access to guns. Changes in daycare/school/after-school care: Does not attend daycare Developmental History: Mother reports the child is not hitting developmental milestones because of his down syndrome. Child does not say many words. HPI: 26-month-old male brought to the ED by his mother who states he has been complaining of abdominal pain for 2 days, vomited, is lethargic, diaphoretic, tachypneic, and has decreased urine output. Mother reports these symptoms started shortly after “falling out of bed.” Mother denies head trauma. Mother denies history of similar symptoms requiring medical attention. Medications: None PMH: Allergies: NKDA Chronic Illnesses/Major traumas: Down Syndrome Hospitalizations/Surgeries: Atrial septal defect repair Family Medical History Mother has anemia, father has no known history, one older sibling has asthma Social History Current living situation/partner/marital status: Mother, mother’s boyfriend, and 2 siblings Firearms in home: Mother denies guns in the home Safety status: Mother reports the child rides in a car seat and feels safe in the community Chiocca, E. M., (2015). Advanced Pediatric Assessment (set ebook; 2nd ed.). Springer Publishing. ISBN: 9780826128683 Cleek, E. A., Johnson, N. L., & Sheets, L. K. (2019). Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations. Child Abuse & Neglect, 92, 167–178. https://doi.org/10.1016/j.chiabu.2019.02.012 Liu, B. C. C., & Vaughn, M. S. (2019). Legal and policy issues from the United States and internationally about mandatory reporting of child abuse. International Journal of Law and Psychiatry, 64, 219–229. https://doi.org/10.1016/j.ijlp.2019.03.007 Karmazyn, B., Duhn, R., Jennings, S., Wanner, M., Tahir, B., Hibbard, R., … Wanner, M. R. (2012). Long bone fracture detection in suspected child abuse: contribution of lateral views. Pediatric Radiology, 42(4), 463–469. https://doi.org/10.1007/s00247-011-2248-3 Palusci, V. J. (2017). Child Abuse : Children with Disabilities. Hauppauge, New York: Nova Science Publishers, Inc. Retrieved from https://search-ebscohost-com.southuniversity.l ibproxy.edmc.edu/login.aspx?direct=true &db=nlebk&AN=1562829&site=eds-live Turner, R. A., & Rogers, H. O. (2012). Child Abuse : Indicators, Psychological Impact and Prevention. New York: Nova Science Publishers, Inc. Retrieved from https://search-ebscohost -com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=nlebk&AN=541949&site=eds-live [Show More]

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