Well Child SOAP Note
ID: “M,” born on January 24, 2009, 13 years old, Caucasian female. She presented today for an appointment at the clinic alone M appears to be a valid source of information.
Subjective:
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Write My Essay For MeCC: “here today for a routine well-child visit.”
HPI: 13-year-old Caucasian female presents to the clinic today alone for well-child visit. M seems to be in good spirits and sitting on the chair. M reports that her last visit was one year ago. No lab work was done in the previous visit.
Childhood vaccinations and flu shot vaccinations are up to date. Last dental exam was four months ago
PMH:
General Health: M denies any new health conditions that have occurred since the last visit.
Psychiatric: M denies
Surgery: M denies
Allergies: M reports that she has an allergy to peanuts. And that when she eats peanut, she
developed a rash and her throat swell. She uses Epi-pen for her allergy.
Medications: Epi-pen PRN, Flintstone vitamin
Family History: Maternal grandmother is alive and well. Maternal grandfather has hypertension.
Father is alive and well, and the mother has no medical history. M is not aware of any medical history on the father’s side.
Social History:
M lives with both his mother and his father in a house. Mother and father both do not smoke, nor drink, or do drugs. M reports that he is highly active. M reports that he sleeps 9hrs through the night and stays asleep till morning. M reports no snoring or breath problems while sleeping.
Safety: M patient does wear any helmet when playing. M wears seatbelt when riding the family car, and both parents wear seatbelts every time. M state that her parent owns a gun, but the gun is in the safety place.
Immunization: Schedule (CDC, 2022). Up to date.
CDC vaccination schedule shown in yellow, green, and purple.
Immunization Time/age received
Hepatitis B
1st dose at birth, 2nd dose at 2 months old, 3 rd dose at 15 months old
DTap
1st dose at 2 months old, 2nd dose at 4 months old, 3rd dose at 6 months old, 4th dose at 18 months old, 5th dose at 5 years old
Hemophilus influenzae type b
1st dose at 2 months old, 2nd dose at 4 months old, 3rd dose at 12 months old, 4th dose at 15 months old
Pneumococcal conjugate
1st dose at 2 months old, 2nd dose at 4 months old, 3rd dose at 6 months old, 4th dose at 15 months old
Inactivated poliovirus
1st dose at 2 months old, 2nd dose at 4 months old, 3rd dose at 15 months old, 4th dose at 5 years old
Influenza
Annually, last one at 6 years old
Measles, mumps, rubella (MMR)
1st dose at 15 months old, 2nd dose at 5 years old
Varicella
1st dose at 15 months old, 2nd dose at 5 years old
Hepatitis A
2 dose series at 15 months old
Meningococcal
–
Spiritual Affiliation: Christian
Feeding History: Normal appetite, healthy food choices including vegetables and fruits by the
parents, denies difficulty chewing, denies concerns with eating.
Developmental History and Milestone: Denies concern for growth and developmental milestones,
Review of Systems:
Constitutional: M denies fever, chills, loss of appetite, fatigue, weight loss.
Head: M denies concussions or irregular head shape.
Eyes: M denies eye infection, irregular gaze, or visual problems.
Ears: M denies hearing problem, ear infections, or draining ears.
Nose: M denies runny nose, cold, loss of smell, and difficulty breathing.
Mouth/Throat: M denies sore throats, tonsil inflammation, mouth breathing, snuffling, apnea, and oral thrush.
Cardiac: M denies cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, and palpitations.
Respiratory: M denies wheezing, cough, purulent or bloody sputum.
Gastrointestinal: M denies difficulty swallowing, diarrhea, constipation, vomiting, hematemesis, jaundice, abdominal pain, and colic.
Genitourinary: M denies frequency, dysuria, hematuria, discharge.
Musculoskeletal: M denies joint pains, gait changes, and swelling.
Integumentary/Breast: M denies rashes, lesions but reports a flat dark birthmark on the back.
Neuro: M denies seizure and motor weakness.
Psych: M denies anxiety and mood changes.
Endocrine: M denies any weight gain, polydipsia, and polyphagia.
Hematological/Lymphatic: M denies bruising easily or excessive bleeding.
Allergy/Immunology: Allergic to peanuts.
Objective:
Vitals: BP: 108/60 HR: 80 RR: 18 Temp: 98.6 (oral)
Height: 65in
Weight: 146lbs
BMI: 24.1
CDC Growth Chart (CDC,2021)
Physical Exam:
General Survey: Appears alert and oriented. He appears happy and well taken care of by his parents. He arrived with his mother, well dressed, and groomed. M is alert and oriented and appears to be a reliable source for todays’ visit. M stated that she travels recently to Kentucky to see the ARCH and had a pet name Bishop.
Head: Head is symmetrical, and there are no lumps, bruises, scabs, rashes, or pains upon inspection. There is no depressions or soft spots noted upon palpation
Eyes: Wear glass and last eye exam was last year, the red reflex was present in the right and the left eye. The optic discs were well defined, and pupils were round, reactive to light, and accommodating bilaterally. Extraocular movements were tested bilaterally to check for the function of cranial nerves three, four, and six. Sclera appeared white, and the corneal was clear. was midline and symmetrical. Nares are patent, and turbinate is pink and moist. No tenderness
Nose: Th nose was in the maxillary and frontal sinuses upon palpation.
Throat: Lips are moist and salivary ducts are open. The buccal mucosa is moist and pink, and the gingiva was pink and not bleeding with no lesions. Tonsils are graded as a +2 bilaterally. The teeth count is 24. Tongue strength is a +5 bilaterally and does not deviate to the right or left. Uvula raises, and hard and soft palate are intact. Can swallow without difficulty. The trachea was midline.
Neck: Normal ROM noted in flexion, extension, bilateral rotation, and lateral bend. Lymph nodes appear soft and movable in the submental region, submandibular region, supraclavicular region, and the anterior and posterior part of the neck. There is no enlargement of thyroid and moves with swallowing. No lymphadenopathy when palpated.
CV: Regular rate and rhythm, S1 and S2 were heard, no murmurs or bruits noted. No lower extremity swelling was noted.
Resp: Chest expansion is equal on the right and left, and thorax is symmetrical. AP ratio is 1:2. No tenderness in the thorax was noted, and lungs are resonant bilaterally. Lung sounds clear in all lobes bilaterally to auscultation.
GI: Abdominal area is flat, and no bruising or tenderness was noted. Bowel sounds are heard in all four quadrants and are normoactive. No pain was reported in light and deep palpation in all four quadrants.
GU: No trauma noted, redness or irritation noted.
M/S: Has full ROM in all joints, including the spine’s cervical, thoracic, and lumbar areas. No pain upon palpation in the extremities or the spine.
Skin: Color appropriate for ethnicity, dry and warm. There are no bruises, rashes, or open wounds noted.
Neuro: Alert and oriented to place and name and follow simple commands.
Psych: Appears to be happy and in a calm mood during the exam.
Assessment:
Differential Diagnosis:
Wellness Visit (Z00.129) – As evidence by delivering a full assessment of the growth and development of the child (Borges Rodrigues et al., 2020).
Food allergy, peanuts (Z91.010) – As evidence by a severe generalized rash. Epi-pen can be used in anaphylaxis allergic reactions to open airways in times of emergency (Greenshaw et al., 2020).
Immunization (Z23) – Immunization is needed, as evidence by not having the influenza vaccine yearly and meningococcal shot this year. (CDC, 2021).
Diagnosis:
Well-child visit.
Diagnostic Plan: No further diagnostic imaging or labs are needed.
Plan:
Schedule next visit next year for annual flu shot.
Give Influenza and Meningococcal vaccination today. Influenza vaccination should be performed yearly according to the CDC vaccination list (CDC, 2021)
Refill epi-pen injection –Patients greater than or equal to 30 kg (66 lbs): AUVI-Q 0.3 mg (Auvi-Q, 2019).
Referrals: None
Education:
Educate on the importance of influenza vaccination and its symptoms. (Pivovarov, 2020). In addition, reinforce education on the importance of all required vaccination (Borges Rodrigues et al., 2020).
Educate on how to use epi-pen (Auvi-Q, 2019).
Educate on limiting media time to one hour per day by using distractions such as media-free play and reading books.
Follow-up plan: Follow-up wellness visit next year.
References:
Auvi-Q. (2019). Epi-pen injection and dosing. Retrieved July 22, 2021, from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6180fb40-7fca-4602-b3da-ce62b8cd2470&type=display
Borges Rodrigues, S., Parisod, H., Barros, L., & Salantera, S. (2020). Two sides of the same well-child visit: Analysis of nurses’ and families’ perspectives on empowerment in health counseling. Journal of Advanced Nursing, 76(12), 3448–3463. https://doi.org/10.1111/jan.14554
Centers for Disease Control and Prevention [CDC]. (2019). Clinical growth charts Boys BMI-for-age. Retrieved July 12, 2021, from https://www.cdc.gov/growthcharts/data/set1clinical/cj41c024.pdf
Centers for Disease Control and Prevention [CDC]. (2021). Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2021. Retrieved July 12, 2021, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Greenhawt, M., Shaker, M., Wang, J., Oppenheimer, J. J., Sicherer, S., Keet, C., Swaggart, K., Rank, M., Portnoy, J. M., Bernstein, J., Chu, D. K., Dinakar, C., Golden, D., Horner, C., Lang, D. M., Lang, E. S., Khan, D. A., Lieberman, J., Stukus, D., & Wallace, D. (2020). Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis. The Journal of Allergy and Clinical Immunology, 146(6), 1302–1334. https://doi.org/10.1016/j.jaci.2020.07.031
Hagan, J. (2017). Bright Futures : Guidelines for Health Supervision of Infants, Children, and
Adolescents. American Academy of Pediatrics.
Pivovarov, J. D. (2020). Flu vaccine cuts pediatric hospitalizations by over 40%. Chest
Physician, 15(12), 36–37.
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