SOAP NOTE

Name:  L.R

Date: 04/09/18

Sex: Female

Age/DOB/POB: 6 Months / 10/10/2017/Miami, FL

SUBJECTIVE

Historian: Mother

Present 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: None

Immunizations: up today

Family History

Mother- 27 years old. Alive and well

Father- 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

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

Head circumference: 42 cm

Height

26 inches

Pulse 116

Resp: 21

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

Cardiovascular

Regular heart rate and rhythm. S1 and S2 present. No gallops, bruits or thrills present.

Respiratory

Unlabored respirations. Lungs clear in all lung fields.

Gastrointestinal

Soft abdomen without tenderness or guarding. Bowel sounds active and normal in all quadrants

Breast

Tanner stage 1.

Genitourinary

Tanner stage 1. No pubic hair, No rashes, no bruises or no lesions. Hymen intact.

Musculoskeletal

Full ROM of all extremities. Good muscle tone and strength

Neurological

Present Barbinski reflex. Patient turns toward finger rub. Maintains head control without assistance

Psychiatric

Smiling and easily comforted by mother

In-house Lab Tests – document tests (results or pending)

None

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For 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 immunizations

Primary 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.html

Woolfenden, 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