soap note

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: NoneImmunizations: up today
Family HistoryMother- 25 years old. Alive and wellFather- 29years old. Alive and wellGrandmother :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
GeneralDenies for fever, lethargy, difficulty arousing or irritabilityCardiovascular Denies for cyanosis, swelling or activity intolerance
SkinDenies rashes, urticaria, lesions or birthmarksRespiratory Denies cough, difficulty breathing or wheezing
EyesDenies strabismus, eye irritation or dischargeGastrointestinalDenies decreased appetite, reflux, burping or diarrhea 
EarsDenies for ear tugging or dischargeGenitourinary/GynecologicalDenies for anuria, changes in color of urine or discharge 
Nose/Mouth/ThroatDenies nose congestion, nose bleeds, or mouth soresMusculoskeletalDenies for fractures or contractures
BreastDenies for lumpsNeurologicalDenies syncope, seizures, epilepsy or tremors
Heme/Lymph/EndoDenies blood transfusions, inability to growth, or sweet odor of urine or sweatPsychiatricDenies difficulty falling asleep or staying asleep
OBJECTIVE
Weight       15 lbsTemp 97.5 FHead circumference: 42 cm
Height26 inchesPulse 116 x’RR: 21 x’SpO2: 99% at Room air
General Appearance and parent‐child interactionWell- nourished, healthy looking patient held in arms by mother. Both look happy.
SkinSkin is warm to the touch and dry. No rash, lesions or bruising.
HEENTHead: Normocephalic head, oval shape and no traumas. Closed posterior fontanelle.Eyes: Pupils PERRLA. Present red reflexes on both eyesEars: No tenderness. Pink tympanic membranesNose: Normal turbinates. Septum midlineMouth: 2 bottom central incisors.Throat: No erythema of exudatesNeck: Supple without masses or thyroid enlargement
CardiovascularRegular heart rate and rhythm. S1 and S2 present. No gallops, bruits or thrills present.
RespiratoryUnlabored respirations. Lungs clear in all lung fields.
GastrointestinalSoft abdomen without tenderness or guarding. Bowel sounds active and normal in all quadrants
BreastTanner stage 1.
GenitourinaryTanner stage 1. No pubic hair, No rashes, no bruises or no lesions. Hymen intact.
MusculoskeletalFull ROM of all extremities. Good muscle tone and strength
NeurologicalPresent Babinski reflex. Patient turns toward finger rub. Maintains head control without assistance
PsychiatricSmiling and easily comforted by mother
In-house Lab Tests – document tests (results or pending)NonePediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationaleFor adolescents (HEADSSSVG Assessment)Assessment conducted during this visit: PEDS score of 0 (no concerns)Parents’ Evaluation of Developmental Status, or PEDS, is an evidence based screening tool that elicits and addresses parental concerns about children’s development, health and wellbeing. PEDS is a simple, 10-item questionnaire that is completed by the parent.According to Woolfenden et al., (2014), this questionnaire in 95% is simple to understand in 95% of the parents no matter their background level or educations. Its purpose is to discover concerns and address certain areas of development with the appropriate timely referrals for follow up.
 Diagnosis
. Differential diagnosis-. Z00.129: Well child exam: This is a visit from the healthy child to comprehensively evaluate the child in his growth progress and if he is reaching the milestone for his age it is done through an interview and a physical examination of the children to detect how well he is doing or if something is developing that can be detected, is examined as the sleep pattern the nutrition dental care if you had to visit recently urgencies and postpartum screening for the mother.. Z 71.3: Dietary counseling and surveillance: Nutritional counseling can help improve dietary habits by increasing the average daily intake of essential components of a healthy diet – reductions in saturated fat consumption and increase in fiber, fruit and vegetable consumption. Counseling can be delivered by primary care clinicians or specialists including nutritionists and dieticians.. Z23: Encounter for immunizations: This is an encounter for administration of the vaccination according to the child age and also for education regarding to what can diseases the child will develop immunization, schedule, side effect .Primary Diagnosis:. Z00.129: Well child exam
PLAN including educationToday child received the 3rd dose for the following vaccines:· DTaP,· IPV,· Hib,· HepB,· Rotateq,· PCV 13
Education:The education for this encounter, include the anticipatory guidance and this encompass:Education of the mother regarding to the importance of preventive such as:Vaccination education, schedule, and side effects, which are inflammation or redness sites after administrations, some low grade fever, and fussiness, (CDC, 2017).Safety in the car and at home:Have the smoked detector at home and may sure that they are working properly and changes the batteries.Always before bathing check the water temperatures to ensure that is adequately.Protect your child from injury. Use gates on stairways and doors. Install operable window guards on all windows above the first floor. Remove sharp-edged or hard furniture from the room where your child plays.Place your baby’s crib away from windows. Cords from window blinds and draperies can strangle your child. Use cordless window coverings, or if this is not possible, tie cords high and out of reach. Do not knot cords together.Use of car safety seats every time your child is in the car. All infants and toddlers should ride in a rear-facing car.Nutrition: Introducing fruits, salads and veggies is important. Continue breastfeeding if desired and possible. Breast milk continues to provide excellent nutrition to the baby.Anticipatory guidanceDental care must be implanted as patient already has 2 teeth. Use a soft brush and clean with water twice dailyAvoid use of television or other technological devices for distractionReading and spending time with the baby as well as establishing a routine are excellent methods to ensure a healthy developmentNext follow up appointment at 9 moths or as needs if there are any concerns.Self -Evaluation for this encounter.This is 6 months’ year old Hispanic female. She is a well develop child for her age, and for this encounter is Well child exam for healthy children, according to The Bright Futures/American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the “periodicity schedule.” It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. After I gathered the information in the interview for the mother and the physical examination I performed, I presented this well child case to my preceptor for discussion, who was agree with the proposed course of action. The mother was instructed the importance of this visit even if the child is normal because then us as a health care provider have the opportunity work together and tracking the growth and development of the child as well we can review together the child vaccination schedule besides if there is concern that could be arisen in topic of the development, behavior, sleep, eating, this visit gives us an opportunity to develop a team approach, regular visit develop strong and trustworthy relation between parent and health care provider. Mother is aware of the next appointmentReferences:Centers for Disease Control and Development [CDC] (2017, January 3). Child development: Developmental monitoring and screening for health professionals). Retrieved from https://www.cdc.gov/ncbddd/childdevelopment/screening-hcp.htmlWoolfenden, S., Eapen, V., Williams, K., Hayen, A., Spencer, N., & Kemp, L. (2014). A systematic review of the prevalence of parental concerns measured by the parents’ evaluation of developmental status (PEDS) indicating developmental risk. BMC Pediatrics, 14(1), 231-244. doi:10.1186/1471-2431-14-231
 

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