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Running head: TODDLER SOAP NOTE 1 Primary Care: Pediatrics Primary Health Care of Family III NUR604 Practicum FOCUSED SOAP NOTE #3 2 SOAP Note Pediatric & Adolescent Medicine Identifying Data: Date of Visit: June 4, 2019 Patient Name: T.M. Age: 2 ye$23.49
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Running Head: TODDLER SOAP NOTE 1 Primary Care: Pe
Running head: TODDLER SOAP NOTE 1 Primary Care: Pe
Exam (elaborations)
Running head: TODDLER SOAP NOTE 1 Primary Care: Pediatrics Primary Health Care of Family III NUR604 Practicum FOCUSED SOAP NOTE #3 2 SOAP Note Pediatric & Adolescent Medicine Identifying Data: Date of Visit: June 4, 2019 Patient Name: T.M. Age: 2 ye
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Running head: TODDLER SOAP NOTE 1 Primary Care: Pe
Institution
Running Head: TODDLER SOAP NOTE 1 Primary Care: Pe
Running head: TODDLER SOAP NOTE 1
Primary Care: Pediatrics
Primary Health Care of Family III NUR604 Practicum
FOCUSED SOAP NOTE #3 2
SOAP Note
Pediatric & Adolescent Medicine
Identifying Data:
Date of Visit: June 4, 2019
Patient Name: T.M.
Age: 2 years and 4 months
Sex: Ma...
Primary Health Care of Family III NUR604 Practicum
, FOCUSED SOAP NOTE #3 2
SOAP Note
Pediatric & Adolescent Medicine
Identifying Data:
Date of Visit: June 4, 2019
Patient Name: T.M.
Age: 2 years and 4 months
Sex: Male
Ethnicity: African American
Date of Birth: 2/02/2017
Visit Type: New Patient
SUBJECTIVE DATA:
TM is a 2 years old, male toddler, the mother and aunt have made the visit because they have
noticed TM pulling and trying to poke at his Rt ear for 2 days now. The mother is worried as
TM seems frustrated and has become irritable, and his ear is showing redness. TM is her first
child and she has brought her Aunt who helps her care for TM.
Chief Complaint (CC):
The Mother states “TM keeps pulling and rubbing his Rt ear for almost two days.”
History of Present Illness (HPI):
The mother states that TM had a cold the previous week with a fever of 101.8, but in
two days he was better and until yesterday night she noticed that TM was pulling on
his Rt ear, and looked distressed, she thought that maybe he had shampoo so she
flushed his ear out with warm water, and used a damp cloth to clean the ear cannel.
But before she went to bed around 9 PM, she heard TM crying, and when she went to
check on him he was awake and puling on his Rt ear, she thinks it may be an ear
infection, but is worried even more now as her Aunt told her that sometimes small
insects can get lodged in children’s ears. She states that her apartment is clean, and
no insects have been seen, but she really wants to find out what is wrong and get it
taken care of. The mother states that TM is not as playful, or happy as he usually is,
and does not want to be held for too long by her Aunt, or by her. The mother states
that she tried to do a visual exam for foreign bodies in TM’s ear with her cellphone’s
light but could not see anything unusual. The mother states that TM has not showed
any symptoms of being sick again, no coughing, runny nose, fever, vomiting,
diarrhea, or loss of appetite. Mother states that TM has not been in contact with any
other children, or has been outside playing or swimming, he has only been out with
her Aunt grocery shopping or running errands.
OLDCART:
Onset: 2days ago
Location: Rt ear
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