EEEE
grandma
3 years ago
1
files (1)nextsoap.pdf
nextsoap.pdf
Evalynn M
DOB: 11/4/2019 Sex: F August/4/2023
Encounter Type: Office Visit
SUBJECTIVE:
Chief Complaint:
Patient is a 3-year-old female accompanied by parents presenting with intermittent cramping last
time. No more cramping today. That improved. Also had pruritus of the buttocks. That
improved. No more pruritus. Used to having regular daily bowel movements. Daily regular BM.
Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recent
illness. Patient denies any history of previous adverse reaction to vaccines. Patient have no
known allergies to medications.
Sick contact: dogs with pinworm
Social History:
Smoking Status: Never Smoked
OBJECTIVE:
Vital Signs:
Height: 104.50 cm
Weight: 17.35 kg
BMI: 15.89
Blood Pressure: 105/61 mmHg
Temperature: 36.50 C
Pulse: 105 beats/min
Resp. Rate: 24
Physical Exam:
Constitutional: Well developed. Well nourished. No acute distress.
Neck: Full ROM, trachea midline position
No thyromegaly
Respiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterally
No wheezing
Cardiovascular: No lifts, no heaves, or thrills No cyanosis
S1S2 RRR (-) murmur
No murmurs, rubs, gallops
Femoral pulses symmetrical
Chest/Breasts: Symmetrical No nipple discharge
No lumps, masses, or tenderness
Gastrointestinal (Abdomen): No masses or tenderness No hernias
Liver and spleen non-tender, not enlarged
Genitourinary: Female G/U: No external masses, lesions, scars
No vulvar rashes or swelling
Labia, clitoris, vaginal orifice, urethral meatus intact, without discharge
Lymphatic: No cervical adenopathy
(-) axillary adenopathy
No subclavian adenopathy
No epitrochlear adenopathy
(-) occipital adenopathy
Musculoskeletal: Digits are w/o clubbing or cyanosis
Equal leg length No back deformities
No misalignment, defects, or deformities
No Scoliosis No muscle atrophy or weakness.
Skin: Digits are w/o clubbing or cyanosis
Equal leg length No back deformities
No misalignment, defects, or deformities
No Scoliosis No muscle atrophy or weakness.
Neurological/Psychiatric: Normal tone Normal power Normal gait
ASSESSMENT:
Assessments:
ICD-10 Assessments:
3 year old girl for P/E.
Appropriate G and D
PLAN:
Immunizations:
Immunizations currently up to date.
Care Plan:
ANTICIPATORY GUIDANCE
No barriers to learning
Safety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,
passive smoke.
Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need for
independence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginary
playmates, enuresis.
Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,
repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and let
children choose).
BARRIERS TO LEARNING: Age Culture Religion
Language Emotional Limited Cognition
Limited Hearing Limited Vision
Readiness to learn Yes No
Learning preferences:
CBC PB PPD
Other lab:
Immunizations: (Check immunization card, document previous immunization, update if
necessary) DTaP No. HIB / HBV No. Prevnar No.
IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) Pentacel
RTC: days wks mos. PRN
Patient Instructions:
F/U for September Flu shot. Encouraged to drink extra prune juice twice a day: morning and
evening.
Evalynn M
Patient ID: 100294528 DOB: 11/4/2019 Sex: F Account No.:
Encounter ID: 283756022 Encounter Date: 07/21/2023
Encounter Type: Office Visit
SUBJECTIVE:
Chief Complaint:
Patient is a 3 year old female accompanied by parents presenting with intermittent cramping
10/10 abdominal pain x1 week, worsens at night. Also has pruritus of the buttocks. Parents report
seeing white dots on buttocks, possibly "eggs." Reports constipation, has 3 bowel movements per
week. Used to have regular daily bowel movements. Tried olive oil, which helped at first but did
not end up resolving symptoms. Tried prune juice with no improvement. Has been eating less,
small meals throughout the day.
Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recent
illness. Patient denies any history of previous adverse reaction to vaccines. Patient has no known
allergies to medications.
Sick contact: dogs with pinworm
History Of Present Illness:
Diet: picky / balanced diet; 3 meals/day, has been eating less
Sleep: 8 hours daily
Elimination: Tvoids 3-4 times per day.
Activity: Lives at home with mother, father, brother, and grandparernts. Attends daycare.
Sick contacts: none reported
Social History:
Smoking Status: Never Smoked
OBJECTIVE:
Vital Signs:
Height: 103.80 cm
Weight: 16.45 kg
BMI: 15.27
Temperature: 36.90 C
Pulse: 88 beats/min
Resp. Rate: 22
Head Circumference: 49.00
Physical Exam:
Constitutional: Well developed. Well nourished. No acute distress.
Eye: red reflex present bilateral PERRLA Sclera white, conjunctive clear No strabismus
Ear: No scars, lesions, or masses Canal walls pink, without discharge
Nose: Mucosa and turbinates pink Nares patent
Mouth: Gums pink Lips pink and symmetrical Oral mucosa pink / moist No cleft palate
Tongue moist, no ulcers
Neck: Full ROM, trachea midline position
No thyromegaly
Respiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterally
No wheezing
Cardiovascular: No lifts, no heaves, or thrills No cyanosis
S1S2 RRR (-) murmur
No murmurs, rubs, gallops
Femoral pulses symmetrical
Chest/Breasts: Symmetrical No nipple discharge
No lumps, masses, or tenderness
Gastrointestinal (Abdomen): No masses or tenderness No hernias
Liver and spleen non-tender, not enlarged
Genitourinary: Female G/U: No external masses, lesions, scars
No vulvar rashes or swelling
Labia, clitoris, vaginal orifice, urethral meatus intact, without discharge
Lymphatic: No cervical adenopathy
(-) axillary adenopathy
No subclavian adenopathy
No epitrochlear adenopathy
(-) occipital adenopathy
Musculoskeletal: Digits are w/o clubbing or cyanosis
Equal leg length No back deformities
No misalignment, defects, or deformities
No Scoliosis No muscle atrophy or weakness.
Skin: Digits are w/o clubbing or cyanosis
Equal leg length No back deformities
No misalignment, defects, or deformities
No Scoliosis No muscle atrophy or weakness.
Neurological/Psychiatric: Normal tone Normal power Normal gait
ASSESSMENT:
Diagnosis:
ICD-10 Codes:
1)B80; Enterobiasis
2)L290; Pruritus ani
3)R1084; Generalized abdominal pain
4)K5901; Slow transit constipation
Assessments:
ICD-10 Assessments:
3 year old girl for P/E.
Appropriate G and D
PLAN:
Procedures:
1) 99214; Office Visit Established Mod-High 25 min
Medications:
Mebendazole Powder; Take 1 tablet (100mg) and chew x 1; Qty: 1; Refills: 0
Immunizations:
Immunizations currently up to date.
Care Plan:
ANTICIPATORY GUIDANCE
No barriers to learning
Safety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,
passive smoke.
Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need for
independence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginary
playmates, enuresis.
Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,
repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and let
children choose).
BARRIERS TO LEARNING: Age Culture Religion
Language Emotional Limited Cognition
Limited Hearing Limited Vision
Readiness to learn Yes No
Learning preferences:
CBC PB PPD
Other lab:
Immunizations: (Check immunization card, document previous immunization, update if
necessary) DTaP No. HIB / HBV No. Prevnar No.
IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) Pentacel
RTC: days wks mos. PRN
Patient Instructions:
- discuss about differential diagnosis of abdominal pain: constipation with diarrhea presentation
or hard stool,
- pinworm for itching perineal at night
- discuss that the diagnosis is based on identifying pinworm during night with scotch tape;
and discuss how to do it
- risk/benefits/alternative discuss about just treating it
- Constipation
- will give 3 days of pedialax at night in a row to clear possible diagnosis of constipation
- follow up in 2 weeks; may need another dose of mebendazole 100 mg/week
This is for next week problem soap note. Use the same template. (You can take your time)
3yrs old girl came twice to Doctor office. First time July. Second time Aug.
The reason was abdominal pain and constipation, pruritus(mom believed the abdominal pain is caused
by pinworm at that time by touching their dog))
However now all solved happily. You can modify the story.
