soap note

Name:  E.F
Sex: Female
SUBJECTIVE
Historian: MotherPresent Concerns/CC:  “I’m here today for the 6 months check- up of my baby”
Child Profile:6 months old infant brought by her mother. Information obtained by the mother.Patient is breastfed 5-6 times daily. Her mother started to introduce puree diet made at home. 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 is the one who is caring for the patient at home. 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)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- 27 years old. Alive and wellFather- 28years old. Alive and well
Social History Patient lives with both parents. Mother took some time off from work to stay at home with the patient. 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 Barbinski 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)This assessment is performed by having parents fill out a questionnaire of 10 questions. It takes approximately 2 minutes to be completed. According to Woolfenden et al., (2014), this questionnaire is easy to understand to 95% of the parents regardless of their educational level or background. 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. Z 71.3: Dietary counseling and surveillance. Z23: Encounter for immunizationsPrimary Diagnosis:. Z00.129: Well child exam
PLAN including education· Patient will receive the 3rd dose for the following vaccines:· DTaP, IPV, Hib, HepB, Rotateq, and PCV 13
Education· Mother education including preventive care and anticipatory guidance was provided during this visit. Topics included:· Vaccine side effects: low grade fever, inflammation or redness at the infection sites, and fussiness (CDC, 2017).· Safety precautions:- Continue to rise with car seat facing rear.- Have smoked detectors at home and change batteries frequently- Always check water temperature before bathing infant to ensure appropriate water temperature- Avoid giving small pieces or food or small toys to play as they pose a choking risk· 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 guidance· Dental care must be implanted as patient already has 2 teeth. Use a soft brush and clean with water twice daily· Avoid use of television or other technological devices for distraction· Reading and spending time with the baby as well as establishing a routine are excellent methods to ensure a healthy development· Next follow up appointment is at 9 months. Contact healthcare provider before that for any concerns. References: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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