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Well Exam Child Soap Note

Name xxx

United State University

Primary Health of Acute Clients/Families Across the Lifespan-Clinical Practicum xxx

Professor xxx

Date xxx

Well Exam Child Soap Note

SUBJECTIVE

ID: S.J, Age: 8, Race: African American, Gender: Female, Date of Birth: January 15, 2014, Insurance: N/A

CC: “I came for my annual wellness visit.”

HPI: S.J is an eight-year-old female who presents to the clinic for her annualwellness examination alongside her mother. The patient comes in for a her annual checkup and currently has no worrying medical concerns. The patient answers questions accurately and looks healthy. She leaves with her father, mother, and 2 siblings. Her last wellness exam was done on January 5, 2021, and she turned out to be healthy.

PAST MEDICAL HISTORY: The patient was treated for pneumonia in May 2020 using amoxicillin. No surgery history.

CURRENT MEDICATIONS: None.

IMMUNIZATION: Patient has received all recommended immunizations for her age, including Tetanus diphtheria, Tdap, Hpv human papillomavirus, meningococcal, pneumonia, hepatitis B, hepatitis A, Polio, MMR measles, mumps, rubella, chickenpox vavicella, and flu vaccine.

PREGNANCY AND BIRTH HISTORY: Mother says she has never used illegal substances, smoked cigarettes, or consumed alcoholic beverages. She stated that the patient was delivered vaginally at full term, and patient was able to breastfeed without difficulty.

Developmental History: According to the patient’s mother, the patient met all developmental age-related milestones on time.

FAMILY HISTORY: The parents of the patient are both alive and together. The father is 41 years old and is allergic to pollen. The mother is 37 years old and suffers from hypertension, which she manages by a healthy lifestyle and Losartan 25mg PO. The patient has 4 years old twin brothers who are healthy and have no medical history. The patient’s paternal grandmother is 69 years old and suffers from arthritis. The grandmother has been on nonsteroidal anti-inflammatory drugs to manage the condition. The paternal grandfather is 74 years old and suffers from mild dementia. His memory is deteriorating, and he is having difficulties remembering past events. He has been in therapy to help him with his memory.

SOCIAL HISTORY: The patient lives with her father, mother, and younger brother. She studies at a school near her home. She is a performer and wants to be a surgeon when she grows up. She has a friend she schools with called Emma. Both enjoy dancing and are in a dancing class. She enjoys eating pancakes and juice.

DIET: The patient claims to consume red meat twice a week, enjoys cake and sugary drinks, and dislikes vegetables. However, she claims to eat an apple at least twice a week.

SLEEP/STRESS: She goes to bed between 8:00 and 9:00 p.m. and sleeps for at least nine hours.

SAFETY: When riding a bicycle or scooter, the patient take precautions such as wearing a helmet and knee protection. When she is in a vichicle, she also wears a belt.

SPIRITUAL AFFLIATIONS: Christian

REVIEW OF SYSTEMS

GENERAL: The patient disagrees with having a high fever, weight increase, night sweats, change in appetite, weight loss, low exercise tolerance, and fatigue.

HAIR, SKIN, AND NAILS: The patient denies rashes, no color changes, no sunburns, and nodes.

HEAD: The patient denies frequent headaches, visual changes, redness, no injury, or drainage.

NECK: The patient does not feel pain or stiffness in the neck—no noted masses or edema.

EYES: No scotomata, no tearing, no pain. The patient has normal vision. She has itchy eyes due to landscaping.

EARS: The patient denies bleeding, having any hearing difficulties, bleeding, tinnitus. No vertigo.

NOSE: Denies nasal drainage and congestion. Throat: Denies throat or neck pain, sore throat, edema, hoarseness, difficulty swallowing.

MOUTH & THROAT: The patient denies edema, sore throat, complications absorption, hoarseness, no dental complications, no use of dentures.

CARDIOVASCULAR: The patient doesn’t suffer from peripheral edema, chest pain, or palpitations.

GASTROINTESTINAL: The patient disagrees with having abdominal pain. She disagrees with having nausea, disgorging, or cramps.

PULMONARY: Normal

ENDOCRINE: The patient has a normal appetite and denies extreme thirst or unconscious prejudice.

LYMPHATICS: The patient has no tender lymph nodes.

GENITOURINARY: The patient has negative dysuria. Denies difficulty starting/stopping a stream of urine or incontinence.

HAEMATOLOGICAL: denies bruising, blood clots, or history of blood transfusions.

MUSCULOSKELETAL: The patient refutes redness and edema to muscles.

INTEGUMENTARY: Denies rash, hives, dry skin, lesions.

NEUROLOGICAL: The patient has no memory loss or confusion problems.

PSYCHIATRIC: The patient denies extreme sadness, mood fluctuations, or sleeplessness.

ALLERGIC: smoke from cigarettes, pollen.

OBJECTIVE

VITAL SIGNS: Temp 97.8 F, RR 32, HR 85, B/P 100/70, SpO2 100%, BMI 25.63 kg/m², Wt 70 lb , Ht 4.2″.

PHYSICAL EXAMINATION

GENERAL APPEARANCE: Vigilant, well-groomed female. No acute pains were detected. She is presentable.

HEENT: Normocephalic. Atraumatic. Eyes: PERRLA. NAOMI. No nystagmus bilateral, Pupils are equal, round, and sensitive to light reconciliation. Ears: Bilateral outer ears are normal—free from drainage. Nose: Sputum is midline. No alterations. It is symmetrical, and vessels expound in the mutual snout with transparent drainage.

NECK: Flexible and balanced. No tracheal variation. No goiter noted—no inflamed lymph node.

ABDOMEN: The patient has a gentle and non-tender flat belly. There was no inguinal found. No ascites were discovered.

RESPIRATORY: Normal

CARDIOVASCULAR: Denies chest pains, palpitations, extremity swelling, or chest stiffness.

GENITOURINARY: No wing, suprapubic sympathy, or CVA devotion.

SKIN: Skin looks hydrated and glowing.

MUSCULOSKELETAL: No joint malformation was noticed. Her spine aroused straight calibration without any curving.

NEUROLOGIC: No cerebellar signs or symptoms, no neural shortfall.

PSYCHIATRIC: Factual to time. Content and appropriate.

ASSESSMENT

DIFFERENTIAL DX:

Wellness Exam: ICD-10 CM Z00.129. A healthy female who came for a well exam. According to the American Academy of Pediatrics, surveillance should be done at each clinic visit for formal developmental screening.

Other nonmedicinal substance allergy status: ICD-10-CM Z91.048. Patient is allergic to smoke from cigarettes, and pollen, evidenced by patient verbalizing that she experiences sneezing, watering, itchy and red eyes

Dietary surveillance and counseling ICD-10-CM Z71.3 Healthy growth and development of a child are aided by nutritious meals. Following the CACFP, a child should be provided nutritious foods in appropriate portion sizes. The meals include fruits, diary, bread, grains, vegetables and meat or meat substitutes. In addition, the child should be taught about good dietary habits. Juices and sugary drinks should be avoided at all costs. It is important to urge them to drink milk and water.

FINAL DIAGNOSIS: Wellness: ICD-10-CM Z00.129

PLAN

CBC for overall wellness check

Annaul well exam to follow up on immunizations, development, and safety issues.

EDUCATION: the patient was advised to continue maintaining a healthy lifestyle, take in a lot of water, fruits, vegetable, whole grains, fat-free and low diary products. A good vriety of protein-rich food, healthy oils derived from fish and vegetables and (Goolamally et al., 2019). She was also advised to take food rich in calcium to help maintain strong bones. Educate the patient on the importance of having an adult oversee them at all times when swimming to avoid a drowning accident. Educate the mother to seek emergency medical attention if the child experience severe shortness of breath or any other symptoms of an exacerbated allergic response.

Follow up in a month to discuss dietary modifications that will help the child maintain a healthy weight and avoid obesity.

REFERRALS: None at this time

Reference

Goolamally, N., Hamid, S. A., Ramli, A. Z., & Rahim, R. A. (2019). Application of rasch model in measuring the quality of health and wellness final exam questions.