peds SOAP NOTE #2

Please provide the requested information on the template and enter the information on the template form attached.

-Patient: 2 year old Hispanic male

-chief complaint: fell and hit head

-history of present illness: was in his usual state of health until the morning of 5/20/2024 when he climbed onto a suitcase and feel back striking his head onto the concrete in the airport. Patient ambulatory and active after the fall but feel asleep soon after (parents report it was his nap time). Parents report he has been more tired than usual since the fall. Patient reports pain upon head palpitation

history: RSV – Human respiratory syncytial virus 11/2023

Allergies: no known drug allergies, no known food allergies, no known environmental allergies

Plan:

1. Apply ice to back of the scalp to reduce swelling and hematoma.

2. Parents do not want to go to the Emergency Department at this time. Instructed the parents to monitor patient for signs of lethargy. Report to closest Emergency Department for increased sleepiness.

3. Over the counter Tylenol oral suspension 5mL by mouth every 4-6 hours as needed for pain. Max dose of 25mL/24h.

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