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Running head: PEDS SOAP NOTE

Peds Soap Note

Heidi Martinez
Grand Canyon University

Soap Note
CC: Per mom concern about teeth grinding.
HPI: 13-yr old male for evaluation of prominent teeth grinding while sleeping for approximately
one month. Complains of pain with biting at hard food, on occasions. Mother concerned with
anxiety. Pt. does not explain to her. Mother is concerned about his behavior.
Childhood Illness: Immunizations UTD. No history of developmental delays or disorders.
Past Medical History: Negative
Past Surgical History: appendectomy 2011

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Family History: (Father) Alive and well, (Mother) seasonal allergies (Maternal grandmother)
breast cancer (Paternal grandfather) passed away from MI at age 69. Energy drinks daily.
Social History: The patient lives with his mother and father. No exposures to pets, or smoke.
Immunizations UTD.
Current Medications: None
Review of Systems:
General: (-) fevers, (-) chills. (-) Significant unintentional weight change, (-) change in exercise
tolerance.

Head: (-) trauma

Eyes: (-) discharge, (-) eye pain, (-) and redness.

Ears: (-) tugging (-) ear pain, (-) ear drainage.

Nose: (-) epistaxis, (-) nasal drainage

Mouth: (-) sore throat, (-) difficulty swallowing.

Neck: (-) lymphadenopathy (-) nuchal rigidity

Chest: (-) dyspnea, (-) wheezing (-) cough

Heart: no known issues per mother

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GI/GU: mother denies n/v/d, denies difficulty with urination and has normal BM daily.

Musculoskeletal: move all extremities equally

Neurologic: (-) seizures, (-) headaches

Skin: no issues

Psych: as per hpi.

Objective:
Vital Signs: BP 94/59 P: 76 RR: 18 T: 97.6 02: 99% Height: 61.75 inches Weight: 118.2 BMI:
21.79
General: Cooperative, anxious patient with clear and appropriate speech and language. Alert
and oriented to time, place and person. Posture upright, moves easily onto exam table.
HEENT: ENT normal nasal mucose, normal pharynges, external canal normal. Eyes no
redness, no discharge, PERLA. Neck: Supple with full range of motion, non-tender, trachea
midline. Thyroid non-enlarged, non-tender, without palpable mass or nodule.
CHEST: Thorax without distortion, non-tender with symmetric expansion. Lungs CTA x 2, No
Rales or wheezes.
CV: CV: RRR w/o murmur, rub or gallop. S1 and S2. Extremities warm, dry, and well perfused.
ABDOMEN: Abdomen rounds, soft, and non-tender without rash, palpable mass or
organomegaly. Active bowel sounds.

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NEURO: Patient alert, oriented, and appropriate. Move all extremities well. Speech fluent and
words are clear. Pt. is coherent; cognition and insight appear intact.
Psychiatric: Anxious
Labs and Diagnostics:
No labs requested.
Differential Diagnoses with ICD 10 codes:
Bruxism (teeth grinding) ICD10-F45.8 (Primary)
(P) Plan

RX: Motrin 600mg PO TID as need for pain.

Referred to dentist for mouth guard.

Mother educated about the benefits of a pediatric counselor/Psychologist and names

provided.

Patient was counseled on the length of time teeth grinding keep a journal.

Parent and patient advised to seek information for any counseling services through school
district.

Educate patient on brain rest in which entails a low stimulation environment, no

television, computer or video game.

The patient will follow-up in 2 weeks.

Return precautions to go to the emergency department if headache, changes in behavior,

level of conscious, repeated vomiting, weakness or confusion.

PEDS SOAP NOTE

References
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2016).
Pediatric Primary Care (5th Ed.). Philadelphia: Saunders.
Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Scott, LA: Advanced Practice
Education Associates.
Pomeranz, A. J., Sabnis, S., Busey, S., & Kliegman, R. M. (2015). Pediatric decision-making
strategies. Elsevier Health Sciences.

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