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Well, Child SOAP Note

 

ID: “N,” a female Caucasian 8-year-old born on February  24, 2014, came in today for a clinic visit with her mom, and her seems to be a credible source of data.

Subjective:

CC: “I’m here today fo a well check visit.”

HPI: An unaccompanied 8-year-old Caucasian female arrives at the clinic today for a well-child checkup. N is seated on the couch and appears in an excellent mood. N mom  claims that it has been a year from her last visit. The last appointment did not include any lab testing.

Immunizations and the flu shot are up to date , and four months ago was the last time and latest oral evaluation.

PMH:

General Health: N mom reports no arising conditions on her health since the last time she was in the facility.

Psychiatric: N Mon denies the presence of any mental conditions or recent disturbances.

Surgery: N mom denies any major or minor surgery.

Allergies: N momelaborates she is allergic to peanuts; she usually develops swollen throat and body rashes on intake. To relieve the allergy, she uses Epi-pen, one  in school and one with her at all time.

Medications: Vitamin (gummies) and Epi-pen as-per-need.

Family History: N dad has hypertension while grandparentare  healthy and alive.

The mother has no medical history or condition, and the . The father’s side of the family’s medical history is unknown to N.

Social History:

N resides in a home with his mother and father. Neither the father nor the mother vape, drinks, or abuse drugs. N momexplains that she is lively. N momstates she sleeps for more than eight hours straight through the night and doesn’t wake up. N mom claims she doesn’t snore or have any breathing issues at night.

Safety: N wears a helmet during play; also, she and the family use seat safety belts always on the car. N mom  also states that the parents have a gun which is always secured in a unique space.

Immunization:  Schedule (CDC, 2022). It is current.

 

 

Immunization Duration/ Age received

Hepatitis B

Dose 1-birth, dose 2- 2 months, and dose 3-15 months.

 

DTaP

Dose1-2 months, dose2- 4 months, dose3- 6 months, dose4- 18 months old, dose5- 5 years.

Hemophilus influenzae type b

Dose1- 2 months, dose2- 4 months, dose3- 12 months, dose4- 15 months.

Pneumococcal conjugate

Dose1- 2 months, dose2- 4 months, dose3- 6 months, dose4- 15months.

Inactivated poliovirus

Dose1- 2 months, dose2- 4 months, dose3- at 15 months, dose4- 5 years.

Influenza

Yearly, up to six years old.

Measles, mumps, rubella (MMR)

Dose1- at 15 months, dose2- at five years.

Varicella

Dose1- 15 months, dose2- 5 years.

Hepatitis A

Dose2 continuation-15 months.

Meningococcal

 

 

Spiritual Affiliation:N is of Christian dominion.

Feeding History: N appetite levels are normal with the provision of a balanced diet comprising of fruits and vegetables; she has ease in chewing and no eating difficulties.

Developmental History and Milestone: Nmom denies delays in developmental milestones and overall growth.

Review of Systems:

Constitutional: M reports no shivering, fevers, lack of appetite, tiredness, or reduction in body weight.

Head:N mom denies any growths or abnormalities in shape.

Eyes:Nmom denies abnormal vision, infection, poor gaze, and other visual disturbances.

Ears: N mom denies ear drainage, infections, or any hearing problems.

Nose: N momreports no loss of smell, breathing obstruction, running nose, or any colds.

Mouth/Throat:N mom reports no throat inflammation, throat swelling, soreness, mouth breathing, presence of oral thrush, or any obstruction.

Cardiac:  N mom  denies difficulty breathing and reports no murmurs, cyanosis, chest pains and congestion, palpitations, and difficulty in exercise.

Respiratory: N momreports no coughing, wheezing sounds, blood-stained sputum, or difficulty breathing.

Gastrointestinal: Denies nausea, vomiting, altered peristalsis, abdominal pains, jaundice, and sharp pains.

Genitourinary: N mom reports no excessive urination, difficulty urination, painful urination, or any discharge or blood in the urine.

Musculoskeletal: N mom  reports no movement changes, swollen or painful joints, and other alterations.

Integumentary/Breast:N mom  reports she has a birthmark at the back but no skin lesions or rashes

Neuro:N mom reports no convulsions, seizures, twitching, or other motor changes.

Psych: N mom reports no mood alterations, anxiety, or other mental deteriorations.

Endocrine: N mom  reports no excessive hunger, no excessive eating, and no weight gain or weight loss.

Hematological/Lymphatic: She reports no excessive bleeding or abnormality in bruising.

Allergy/Immunology:  M reports an allergy to peanuts.

Objective:

Vitals: BP:  96/60  HR:  80   RR:  20  Temp: 98.6 (oral)  

Height:   50 in

Weight:  60 lbs

BMI: 21.1

 

 

 

CDC Growth Chart (CDC,2021)

Physical Exam:

General Survey:  Seems focused and awake. She seems content and properly cared for by her parents. She appeared well-groomed and clothed, accompanied with her mother. N looks to be a reputable source for today’s appointment because she is focused and aware. N  revealed that that she has a pet ( Turtle )and love ice skating.

Head: On examination, the head is proportional and free of irregularities, scars, open sores, blemishes, or aches. When palpated, there are no downturns or tender patches can be found.

Eyes:N mom stated that she  wear glasses, and her most recent eye checkup was last year; my right and left eyes had a red reactivity. The cornea was clear, and the sclera looked white, equal, and central. The turbinate is pink and moist, and the sinus passages are open. No sensitivity. Binocular extraocular movements were evaluated to determine whether sensory nerves three, four, and six were functioning.  The optic discs were visible, and the pupils were spherical, light-responsive, and symmetrically adaptable.

Nose: The frontal sinuses were open and normal, with no discharge.

Throat: Salivary glands are wide, and lips are wet. Soft and hard palates are unharmed, and the uvula rises. Capable of swallowing easily. Midline tracheal was present.There are 24 teeth. Tongue stiffness is a +5 unilaterally with no right-sided or left-side deviation. The gingiva was pink, not hemorrhaging, and free of ulcers, and the mucous membrane was red and moisturized. Tonsils receive a unilateral rating of +2.

Neck: Contraction, expansion, lateral precession, and horizontal bend all show a normal range of motion. The submandibular, submental, supraclavicular, and front and rear regions of the neck have soft, moveable lymph glands. The thyroid does not expand and moves during ingesting. No palpable lymphadenopathy.

CV:  The S1 and S2 were heard; there was normal rhythm and rate, no bruits and no murmurs, and no swelling and other abnormalities noted.

Resp: Both the right and left sides of the chest expand equally, and the ribcage is equal. A:P is a 1:2 ratio. When the lung is auscultated bilaterally, all chambers sound normal.  The thorax did not exhibit any pain, and both lungs resonated.

GI: There is no redness or soreness, and the belly area is smooth. All four dimensions can hear normal-active bowel movements. Gentle and thorough palpation in the four quadrants revealed no signs of pain.

GU: No irritation, no swelling, redness, or abnormal discharge.

M/S: Has full range of motion in all joints, along with the thoracic, cervical, and lumbar portions of the vertebrae. Palpation of the spine or limbs revealed no discomfort.

Skin: Warmer, dry coloration that is acceptable for the ethnic group. No bumps, blisters, or broken skin are present.

Neuro: ability to follow simple instructions and be particularly attentive to location and identity.

Psych: looks content and at ease throughout the assessment.

Assessment: 

Differential Diagnosis:

• Wellness Visit (Z00.129) – Full assessment of growth and evaluation of developmental milestones(Borges Rodrigues et al., 2020).
• Peanut allergy/Food allergic reaction(Z91.010) – General body rash which requires the use of Epi-pen as an emergency intervention for opening airways (Greenshaw et al., 2020).
• Immunization (Z23) – The need for immunization due to missing annual influenza and meningococcal vaccine or the shot(CDC, 2021).

Diagnosis:

• Wellness of child visit

Diagnostic Plan:  No essential labs or imaging tests.

Plan:

1. One year appointment for the flu shot.
2. Administer Meningococcal and Influenza vaccines as per the CDC protocols (CDC, 2021)
3. Replenish the Epi-pen – clients with 30 kg or more (66 lbs): AUVI-Q 0.3 mg (Auvi-Q, 2019).

Referrals: None

Education:

1. Inform the client of the need for the influenza vaccine and the side effects. (Pivovarov, 2020). Also, informs on the efficiency and the uses of all the vaccines (Borges Rodrigues et al., 2020).
2. Demonstrate the uses of Epi-pen (Auvi-Q, 2019).
3. Educate on the importance of daily exercises and reduce indoor activities like watching television.

Follow-up plan:  One-year appointment.

 

 

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.