Assignment: Soap Note

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Assignment: Soap Note

Assignment: Soap Note

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Assignment: Soap Note
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Name:  E.F Date: 01/17/2019
Sex: Female Age/DOB/POB: 6 Months / 12/06/2017/Miami, FL
SUBJECTIVE
Historian: Mother

Present Concerns/CC:  “I’m here for the check up for his 6 moths”

Child Profile:

This is 6 months old female infant that was brought for her mother. Information was provided by the mother. Per Mom she breastfed her for about 5-6 times daily mother state that she introduced a new element to her diet that is puree that is home made. Mom state that patient has 1-2 bowel movements daily and an average of 9-10 wet diapers. She sleeps 8-10 hours at night and takes 2 naps of approximately 1-2 hours during the day. Mother and grandmother split the time caring for her at home due to Mom work part-time now. Patient is able to move front to back and back to front and sits well with slight support. Patient responds to mother’s voice, giggles, and babbles. Per mother, patient is not exposed to second hand smoking, rides on the back of the car with car seat facing backwards. No guns or pets at home and patient is kept in a hazard free environment.

HPI: (must include all components)

This is 6-month-old female who presents with mother for her 6-month well-visit checkup. No past medical history or current health concerns

 

Medications:

None

PMHX:

Allergies:  NKA

 

Medication Intolerances: None

 

Chronic Illnesses/Major traumas: None

 

Hospitalizations/Surgeries: None

Immunizations: up today

Family History

Mother- 25 years old. Alive and well

Father- 29years old. Alive and well

Grandmother :55 ,HTN ,Alive

Social History

Patient lives with mother and grandmother, she is single Mom. Mother and grandmother caring for the child, Mom work as teacher part-time. Mother denies smoking, guns, pets, or violence at home.

ROS
General

Denies for fever, lethargy, difficulty arousing or irritability

Cardiovascular

Denies for cyanosis, swelling or activity intolerance

Skin

Denies rashes, urticaria, lesions or birthmarks

 

Respiratory

Denies cough, difficulty breathing or wheezing

Eyes

Denies strabismus, eye irritation or discharge

Gastrointestinal

Denies decreased appetite, reflux, burping or diarrhea

Ears

Denies for ear tugging or discharge

Genitourinary/Gynecological

Denies for anuria, changes in color of urine or discharge

 

Nose/Mouth/Throat

Denies nose congestion, nose bleeds, or mouth sores

Musculoskeletal

Denies for fractures or contractures

Breast

Denies for lumps

Neurological

Denies syncope, seizures, epilepsy or tremors

Heme/Lymph/Endo

Denies blood transfusions, inability to growth, or sweet odor of urine or sweat

Psychiatric

Denies difficulty falling asleep or staying asleep

OBJECTIVE
Weight       

15 lbs

Temp 97.5 F Head circumference: 42 cm
Height

26 inches

Pulse 116 x’ RR: 21 x’

SpO2: 99% at Room air

General Appearance and parent‐child interaction

Well- nourished, healthy looking patient held in arms by mother. Both look happy.

Skin

Skin is warm to the touch and dry. No rash, lesions or bruising.

HEENT

Head: Normocephalic head, oval shape and no traumas. Closed posterior fontanelle.

Eyes: Pupils PERRLA. Present red reflexes on both eyes

Ears: No tenderness. Pink tympanic membranes

Nose: Normal turbinates. Septum midline

Mouth: 2 bottom central incisors.

Throat: No erythema of exudates

Neck: Supple without masses or thyroid enlargement

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