1 Pediatric Soap Note Name: G. C
Date: 15 November 2020
Sex: Male
Age/DOB/Place of Birth: 4 years
SUBJECTIVE CC: G. C “has been experiencing severe pain and discomfort in the right ear.” Child Profile: The child lives with her mother but is usually taken to her grandmother during weekends and holidays. Her mother usually takes him to a local daycare in the morning and picks him every evening. The child does not present with developmental abnormalities and plays with his peers. HPI: The client is a 4 years old boy brought to the facility by her grandmother. The grandmother states that the child has been experiencing pain and discomfort in his right ear for two days in a row. The child also shows signs and symptoms of upper respiratory infection including nasal congestion, coughing, and rhinorrhea. These symptoms have persisted for a week. The child appears tired, sleeps almost the whole day and wakes up at night due to earache. Medications: Tylenol 10 ml 3 times daily for fever and pain PMH: Allergies: no history of drug allergies Intolerance to medications: None Chronic Illnesses: The child has a 2 years history of Acute otitis media. Hospitalization: No history of hospitalization or surgery on the client Immunizations: The client’s immunization is up to date. Family History The mother is alive with no significant health issues Grandparents: Grandmother is 74 years old; she has hypertension which is well managed with medications. Social History The client lives with her mother who is a single mother. Her mother smokes cigarettes and drinks alcohol occasionally. ROS General The client does not have a fever. However, he is tired than usual. His appetite has decreased although he has not lost weight. he does not suffer from night sweats Skin Negative for skin rashes and lesions
Cardiovascular The child does not experience chest pain and shortness of breath or palpitations Respiratory Positive for coughing, rhinorrhea, and nasal congestion
Eyes Gastrointestinal Negative for redness, blurry vision, excessive tearing, and No reported change in feeding patterns as well as elimination inflamed eyelids patterns. Negative for pain in the abdomen, diarrhea, and vomiting. Ears Genitourinary/Gynecological Positive for pain in the ear and decreased hearing capacity No changes in urinary patterns, no reported case of hematuria, Grandmother has to shout for the child to hear clearly. pain and burning sensations Nose/Mouth/Throat Positive for nasal congestion, and mucus production Negative for dental pain and oral infections
Musculoskeletal Negative for inflammation of joints and muscles or a decreased range of motion.