Assignment: Soap Note

Assignment: Soap Note
Assignment: Soap Note
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