Well Child SOAP Note

Well Child SOAP Note

Ma Jesska Sabryna Receno

Department of Nursing, United States University

MSN 572: Advanced Health and Physical Assessment Across the Lifespan- Immersion

Dr. Tolulope Adedayo

August 2, 2021

ID: “Kai,” born March 8, 2010, 11 years old, African American male. He presented today for an appointment at the clinic with his mother. The mother appears to be a valid source of information.

Subjective:

CC: “here today for a routine well-child visit.”

HPI: 11-year-old African American male presents to the clinic today with her mother for a well-child visit. Kai seems to be in good spirits and sitting on the chair. The mother reports that Kai’s last visit was one year ago. No lab work was done in the previous visit.

Childhood vaccinations and flu shot vaccinations are up to date. Last dental exam was four months ago

PMH:

General Health: Mother denies any new health conditions that have occurred since the last visit.

Psychiatric: Mother denies

Surgery: Mother denie

Allergies: The mother reports that Kai has an allergy to peanuts. He developed a rash that is warm and red all over his body. He was taken to the emergency department and was given a shot of epinephrine.

Medications: Epi-pen PRN, fluticasone 50mcg daily prescribed by primary provider in the morning for sneezing since 2 weeks ago

Family History: Maternal grandmother is alive and well. Maternal grandfather has hypertension.

Father is alive and well, and the mother has no any medical history. Mother is not aware of any history on the father’s sid

Social History:

Kai lives with both his mother and his father in a house. Mother and father both do not smoke, drink, or do drugs. The mother reports that he is highly active. Kai’s s screen time starts when he gets home from school, and the mother does not limit screen time, but the father does. The mother reports that he sleeps through the night and stays asleep till morning. The mother reports no snoring or breath problems while sleeping.

Safety: The patient does wear any helmet when playing. Kai wears seatbelt when riding the family car, and both parents wear seatbelts every time. The mother denies owning a firearm, and the whole house is childproof