soap note

Name: M. O.Date: 05/21/18
Sex: MaleAge/DOB/Place of Birth: 8 Y/O /04-20-2010/Miami, Florida
SUBJECTIVE
Historian: DadPresent Concerns/CC:“He hurt his right arm.”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.
HPI: (must include all components)8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.
Medications(List with reason for med )None.
PMH:Allergies: NKDAMedication Intolerances: NoneChronic Illnesses/Major traumas: NoneHospitalizations/Surgeries: None Immunizations: Updated
Family History ( Please identify all immediate family)Father alive and well, mother alive and well.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety statusHe lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.
ROS
GeneralDenies, headache, chills, myalgia.CardiovascularDenies chest pain/discomfort, heart problems
SkinDenies rash or lesions.RespiratoryDenies cough, difficulty breathing, wheezing.
EyesDenies discharge from eye, redness, or painGastrointestinalDenies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.
EarsDenies pain or dischargeGenitourinary/GynecologicalDenies dysuria or changes in urinary pattern.
Nose/Mouth/ThroatDenies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowingMusculoskeletalReports injury and pain to left arm
BreastDenies pain or tendernessNeurologicalDenies loss of consciousness, dizziness, headache, or alteration in mental status
Heme/Lymph/EndoDenies weight loss, activity intolerance, heat or cold intolerancePsychiatricDenies depression, anxiety, or suicidal ideation
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 30.3 kgTemp 98.9 FBP 97/59 mmHg
Height 50 inBMI: 18.74Pulse 100 x’Resp 20 x’Sp02
General Appearance and parentchild interaction:No acute distress, well-developed, well nourished, alert.
SkinSkin pink, warm, and dry, no rashes or lesions noted.
HEENTHead normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.
CardiovascularS1S2 audible. Regular rate and rhythm. No murmurs.
RespiratoryLungs clear, good air exchange, no wheezes or rales
GastrointestinalAbdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly
BreastDeferred
GenitourinaryBladder is non-distended; no CVA tenderness, external and internal genitalia not examined.

Pediatric SOAP Note

MusculoskeletalLimited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.
NeurologicalAlert, moves all extremities spontaneously
PsychiatricAge appropriate development.
In-house Lab Tests – document tests (results or pending)Right wrist x-ray – closed fracture at distal radius
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationaleFor adolescents (HEADSSSVG Assessment)
Diagnosis
· 1. Closed fracture of distal end of right radius – S69.91XA· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-ray· Pertinent negatives – no obvious deformity, no swelling· Rationale – Limited ROM following injury or trauma to the arm suggest possible fracture.2. Other specified sprain of right wrist, initial encounter – S63.591A· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM· Pertinent negatives – no obvious deformity, no swelling· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain.3. Dislocation of right wrist – M24.331· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM· Pertinent negatives – no obvious deformity, no swelling· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation.·· Primary diagnoses: Closed fracture of distal end of right radius – S69.91XAPLAN including education· Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)· Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note provided· Administer Tylenol or Motrin every 4-6 hours as needed for pain.· Follow-up with Orthopedics, copy of x-ray CD provided
·
ReferencesArora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.3928/00904481-20140417-12

*ALL references must be Evidence Based (EB)

 

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