Pediatric SOAP Note
Date: 10/4/2012
Name: NB
Race: African American
Sex: Male
Age: 1-year-old (20 months)
(full-term)
Birth weight: 5lbs5oz
Allergies: NKDA
Insurance: Medicaid
Chief Complaint
NB is a 20-month-old male with a new onset of low-grade temperature (99.1), cough, runny nose, and
sneezing. He is brought to office by his foster mother. Foster mother states that child started to cough
last night but no other symptoms at that time. Child was given albuterol treatment last night “about
8pm and this morning about 6 am, and breathing treatment seemed to help with coughing”. Mother
states that the child’s daycare called her regarding the other symptoms (low-grade temperature (99.1),
runny nose, and sneezing) at “2pm”. States that she gave child Motrin 1.8mL at about 4pm and wanted
to bring child in to prevent further resp. issues such as PN
Patient was treated for similar symptoms in this spring x2, during the summer x1 and August x1 with
abx, steroid, and albuterol per mother. Child recovered without any issues.
Past Medical History
Partial agenesis of cerebellar vermis with partial Danny Walker malformation and periventricular
leukomalacia (PVL) {at birth}Down’s Syndrome {at birth}, Asthma {at 13 months-at least 4 exacerbation
in the last 6 months}, Strabismus {at 3 months}, myopia {at 3 months}, Amblyopia (rt eye {at 3 months},),
Developmental Delay (presents as a 7 mth old), hypotonia, PN {at 12 months}, Croup {at 6 months}, OM
(x3 within the past 12 months), and Allergic Rhinitis { within the past 12 months}.
Hospitalization: On 2/15/2012 taken to Children’s in Birmingham for PN. He stayed 7 days.
No injuries or operations
Immunization: All up-to-date per Imprint, Patient to return to clinic for influenza vaccine on October 6,
2012
Medication: Albuterol 0.083% tid as needed, Singulair 4 mg daily, Proair 1 puff bid as needed, Nasonex 1
spray to both nostril at night, Motrin per weight as needed (current dosage 1.8mL), Children MVI daily.
No issues with medication compliance noted
Diet: soft table/finger foods and whole milk
Family History: Child has been living with a foster family since 5 months of age. Child’s biological family
history unknown by foster parent. States she just knows that the child’s birth mother did not seek
prenatal care until she was 8 months pregnant with NB. Current foster mother adoption of child will be
finalized in Dec 2012. Child full name will be changed after adoption .