GI Focused SOAP Note

Patient Information: AM 5 y.o Caucasian Male

S.

CC: Stomacheache and vomiting

HPI: 5-year-old Male here with his mother complaining of diffuse lower abdominal pain for the past 2 days. The pain is in the umbilical region and right lower quadrant. The pain is crampy and persistent. Associated symptoms are decreased appetite, nausea, and emesis nb/nb. Movement makes the pain worse. Motrin and rest make the pain tolerable. The pain is moderate in severity. The caretaker denies any fevers or sick contacts. The caretaker reports that Motrin, Pepto, and probiotics were given with little improvement.

Current Medications: No prescription medications. Motrin 100mg/5mL - Take 4 mL PO q6 hrs, PRN pain, Pepto-Bismol 400 mg Chewable Tablet - Chew 2 tabs PO BID, PRN nausea, Culturelle Probiotics Gummy - Take 1 gummy PO BID.

Allergies: NKDA, no food allergies or sensitivities.

PMHx: He is up to date on childhood immunizations. No injuries or chronic illness. Normal spontaneous vaginal birth without complication. Gestational age 39 weeks 2 days. No surgeries.

Soc & Substance Hx: He lives with his mom, dad, and brother in their home. No exposure to secondhand smoke. They have no pets in the home. They have smoke detectors in the home. He rides in a forward facing safety seat. He is in Kindergarten and doing well - has an IEP. No tobacco, alcohol, or drug use.

Fam Hx: Mom and dad are healthy with no chronic medical conditions. Brother is undergoing autism evaluation, otherwise healthy. Paternal grandfather has hypertension, heart disease, and hyperlipidemia. Maternal grandmother has hypertension, diabetes, autoimmune hepatitis, and thyroid disorder. No family history of IBD or PUD.

Mental Hx: Caregiver has no concerns regarding the patient's mental health or behavior.

Violence Hx: There is no concern for violence in the home. No bullying at school.

Reproductive Hx: NA

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue. Positive loss of appetite.

HEENT: Eyes: No vision changes or yellow sclerae. Ears, Nose, Throat: No ear pain, nasal congestion, runny nose, or sore throat……….. Continue