Pediatric Soap Note Patient Initials Mr. Date Of Encounter 0 ✓ Solved

Pediatric Soap Notepatient Initials Mrdate Of Encounter 05032019s

Provide a comprehensive pediatric SOAP note based on the provided patient case involving a 15-year-old female (MR) presenting for her routine wellness checkup, immunizations, and health assessment. The note should include subjective history (HPI, present concerns, medication, PMH, family history, social history, ROS), objective findings (vital signs, physical exam, lab results, growth charts), assessment (primary diagnosis and differential diagnoses with supporting rationale and ICD-10 codes), and a detailed plan (vaccinations, education, anticipatory guidance, follow-up, and any ordered tests) structured appropriately with relevant subheadings. Use evidence-based sources to justify clinical decisions and include references in proper format.

Sample Paper For Above instruction

Pediatric Soap Notepatient Initials Mrdate Of Encounter 05032019s

Comprehensive Pediatric SOAP Note for Routine Wellness

Patient Initials: M.R

Date of Encounter: 05/03/2019

Sex: Female

Age: 15 years old

Chief Complaint: Routine wellness checkup and update immunizations

Subjective History

Chief Complaint and Presenting Concerns

The patient’s mother reports that the visit is for a routine wellness examination and immunizations. The patient, MR, is a healthy, growth-appropriate adolescent girl attending school with no current health complaints. No recent illnesses, injuries, or hospitalizations are noted. She reports regular menstrual cycles lasting about three days, without sexual activity or significant gynecological issues. Her family has no hereditary illnesses of concern, though her mother is healthy and her father is obese. Socially, MR lives in a supportive nuclear family and has good peer relationships. She is not sexually active, does not use recreational drugs, and maintains healthy habits.

History of Present Illness (HPI)

MR is brought in for an annual checkup with no new or ongoing health issues. She reports feeling well, normal growth and development, and adherence to childhood immunization schedule. No recent weight changes, fever, fatigue, or other systemic symptoms. Menstrual history is normal, with the last period occurring recently. The mother inquires about recommended vaccines and health concerns pertinent to her age.

Medications

  • Tylenol 500 mg as needed for menstrual cramps, every 8 hours.

Past Medical History (PMH)

  • No allergies reported (NKA).
  • No chronic illnesses or major traumas.
  • Hospitalized for appendectomy five years ago.

Family History

  • Mother (35 years) healthy, no significant illnesses.
  • Father (38 years), obese.
  • Grandparents: maternal grandmother with COPD and hypertension; maternal grandfather with a history of CVA. Paternal grandparents healthy.

Social History

  • Lives with both parents; attends high school; performs well academically.
  • No smoking, alcohol, or recreational drug use.
  • Supports autonomy and has good communication with family.

Review of Systems (ROS)

Review indicates no significant abnormalities: no fever, weight loss, fatigue, skin rashes, respiratory symptoms, gastrointestinal complaints, or genitourinary issues. Eyes and ears are normal, no throat symptoms. Musculoskeletal and neurological assessments are unremarkable. Psychosocial review shows no depressive or anxiety symptoms, good school performance, and appropriate behavior.

Objective Findings

Vital Signs

  • Height: 155 cm (50th percentile)
  • Weight: 110 lbs (approximately 50th-75th percentile, BMI 20.8)
  • Temperature: 98.5°F
  • Blood Pressure: 104/62 mmHg
  • Pulse: 65 bpm
  • Respirations: 17/min

General Appearance and Behavior

Well-nourished, alert, cooperative, appropriately dressed, interacts well with examiner and mother. No distress observed.

Physical Exam

Skin

Warm, dry, intact, no rashes or lesions.

Head and HEENT

Normocephalic, atraumatic. Pupils equal, reactive, and accommodating; conjunctivae clear; extraocular movements intact. No oral lesions or dental issues.

Neck

Supple, no lymphadenopathy.

Cardiovascular

S1, S2 normal, no murmurs, rubs, or gallops. Capillary refill

Respiratory

Clear breath sounds bilaterally, no wheezes or crackles.

Abdomen

Soft, non-tender, non-distended, scar from appendectomy; no hepatosplenomegaly.

Genitourinary

External genitalia normal; Tanner stage V, with regular menses.

Musculoskeletal

Full range of motion, no joint swelling or deformities.

Neurological

Alert, oriented x4. Cranial nerves intact. Normal gait, no focal deficits.

Psychiatric

Appropriate mood and affect, good insight, no signs of depression or anxiety.

Laboratory and Assessment Data

  • Snellen visual acuity: 20/20 OU
  • Hearing: Normal
  • Random glucose: 88 mg/dL
  • Urinalysis: Negative dip

Growth chart depicts placement within the 50th to 75th percentile for height and weight, indicating healthy development.

HEADSSSVG assessment completed with no evidence of depression or suicidal ideation.

Assessment

  1. Primary diagnosis: Well adolescent, routine health maintenance (Z00.129)
  2. Differential diagnoses:
  • Normal adolescent growth and development (R62.0)
  • Minor nutritional concerns (Z13.0) — not supported by current findings

These diagnoses are supported by subjective and objective findings consistent with age-appropriate development and absence of any acute or chronic health problems.

Plan

Vaccinations

  • Administered the annual influenza vaccine; vaccine card and documentation provided.
  • Assess for other age-appropriate vaccines: HPV, Tdap, Meningococcal, review immunization schedule, and administer as indicated at subsequent visits.

Health Education & Anticipatory Guidance

  • Discussed importance of maintaining healthy diet, regular exercise, and weight management to prevent obesity-related diseases such as hypertension and type 2 diabetes (CDC, 2018).
  • Instructed on safe sexual practices, even though she reports not being sexually active currently, emphasizing ongoing safe behaviors and consent.
  • Encouraged abstinence from recreational drugs, alcohol, and tobacco; discussed peer pressure and coping strategies.
  • Discussed mental health monitoring, including recognizing signs of depression and suicide risk; instructed parents on maintaining open communication.
  • Promoted skin protection and regular eye and dental care.

Follow-up and Recommendations

  • Schedule routine annual checkup, with immunization review, screening tests as per guidelines.
  • Encourage continued physical activity, balanced diet, and healthy lifestyle choices.
  • Refer to behavioral health only if signs of mental health concerns emerge.

Additional Testing & Referrals

No immediate laboratory or specialist referrals required. Continue routine screening and health education.

References

  • Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G. (2017). Pediatric Primary Care (6th ed.). South University.
  • Centers for Disease Control and Prevention. (2018). Developmental Monitoring and Screening for Health Professionals. CDC.
  • Goolsby, M. J., & Grubbs, L. (2014). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). F. A. Davis.
  • American Academy of Pediatrics. (2017). Guidelines for Adolescent Preventive Services.
  • Hagan, J. F., et al. (2017). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. AAP.
  • Miller, M. L., & Fraga, N. (2017). Pediatric Examination Techniques. Journal of Pediatric Nursing.
  • CDC. (2020). Recommendations on Immunization Schedules for Children and Adolescents. CDC.
  • American College of Obstetricians and Gynecologists. (2016). Well-Woman Visit: Contraception and Counseling. ACOG.
  • World Health Organization. (2019). Adolescent Health and Development. WHO.
  • Shaw, S., & Wilson, J. (2018). Managing Pediatric Well-Care Visits. Pediatrics in Review.

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