Pediatric SOAP Note

Present Concerns/CC:

“We are here for follow up on labs results after frequent episodes of nose bleeds”

Patient is a 2 years old toddler who lives with both parents and grandmother from his mother side. He attends daycare Monday –Friday from 8-5 and the rest of the time is cared at home by his parents and grandmother. He drinks 8 ounces of whole milk x 3 times daily and eats solid foods. He is described as a good eater, and his diet include rice, beans, meat and yogurt. He does not like vegetables or fruits but parents try to include them. Patient has met all his milestones on time. He knows most colors, speaks 4-5 words sentences and is able to count to 12. Patient is in the process of toilet training and only uses pamper at nighttime. Patient sleeps 8-9 hours at night and 2 hours nap during the day. Patient rides in the back seat of the car. All cabinets are locked at home and house has smoke alarms.

2 y/o male born at 39 weeks gestation via uncomplicated vaginal delivery. Seen in the office accompanied by mother for follow up appointment and labs results. Patient had been seen 1week ago due to complaints of frequent nose bleeds. Last episode 1 weeks ago while in office in the presence of the doctor. Bleeding is usually unilateral but can be present in any nostril. Bleeding is usually of short duration and can be easily controlled with finger pressure. Mother denies bruises, easily bleeding, teeth bleeding or melena. Labs ordered showed an unremarkable complete blood count with only abnormal elevation of PT at 50.

None

Allergies:  NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up to date

Mother is 28 years old and does not have a past medical history

Father is 36 years old and is healthy. However, he does report similar episodes of nose bleeds since he was a child. He was told it was nose dryness and was never diagnosed with any other disease

Maternal grandmother suffers has GERD.

Maternal grandfather suffers from Hypertension.

Paternal grandmother has Hypertension

Paternal grandfather has hypertension and suffered a TIA 3 years ago but is stable.

History of bleeding disorder of his maternal uncle

Patient lives with both parents and maternal grandmother in a rented house. Both parents are accounting and they are initiated their own office. He goes to daycare since he was 1 year and 6-month-old. Mother reports no guns at home, and they have smoke and CO2 alarms at home. Patient is an only child. He wears helmets for safety when riding bikes. Both parents are highly involved in his care.

Denies weakness, fever, fatigue, night sweats or malaise

Denies abnormal heart beats, murmurs, or chest trauma

Denies rash, hives, urticarial, bruises or lesions