Pediatric Soap Note



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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.. 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 ..

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