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Pediatric SOAP Note: Yenixis Martinez-Castillo
Pediatric SOAP Note: Yenixis Martinez-Castillo
| NP Student Name: Yenixis Martinez-Castillo | Child’s Initials: D.C | DOB:04/30/15 |
| Clinical Date: 05/17/2019 | Age: 4 Years | Place of Born: Miami, FL |
| Week Soap Project: W3 | Sex:
M x_ F ___ |
Type of Soap Note:
Well child visit __x__ Sick visit ____ |
| SUBJECTIVE | ||
| Historian: Mother
Present Concerns/CC: “ We are here for the yearly exam and immunization update.” |
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| Child Profile: Healthy appearing 4-year-old male. The mother claims the overall health status of her child is good and he is very active and playful.
Activities of Daily Living (age appropriate): He is generally a pleasant child. Feeds on a well-balanced diet and drinks plenty of water and milk after every meal. He dresses appropriately on his and requires minimal help with buttons and zippers. He sleeps at night in his own bed for about 8 hours. Safety Practices: All his baths are always supervised. He is always supervised when playing outside. Changes in daycare/school/after-school care: Daily care is provided by his stay at home mother. Sports/physical activity: He engages in self play with his toys and demonstrates good use of imagination. Developmental History: He is able to climb stairs without help, stand on one foot for about 5 seconds, kick a ball forward, is able to draw circles and stick people figures. His language is also improving as he understands the concept of “same” and “different.” His cognitive abilities are improved as he can correctly name some colors. He is also able to socialize through playing with other children. Sexual History (if appropriate): None Pediatric SOAP Note: Yenixis Martinez-Castillo |
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| HPI: D.C is a 4-year-old male child, is brought to the clinic by his mother for a yearly exam and immunization update. The patient has no previous medical history or any presenting illness or complaints. He appears alert, well hydrated, and nourished. He is appropriately dressed for the weather and situation. His mood is pleasant and cooperative.
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| Medications: None
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| PMH: D.C was a planned pregnancy with appropriate prenatal care. The mother was healthy during the pregnancy period and denies using tobacco, alcohol or any other illicit drugs before, during or after pregnancy. She was compliant with prenatal vitamins and folic acid during pregnancy and three months after delivering. She gained about 35 pounds during pregnancy and delivered vaginally, without any complications. The child is very healthy with no reported infectious diseases or illness.
Allergies: NKDA Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: No hospitalization or surgical history reported. Immunizations: Up to date (DTaP x 4, Hep-A, Hep-B x2, HIB x4, MMR x1, IPV x3, VZV x1, Inflluenza x2)
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| Family Medical History: Mother is 24 years old, and states she is healthy without any PMH or allergies. Father is 23 years old and has a PMH of asthma and environmental allergies; he receives immunotherapy for his allergies and takes Singulair 10 Mg Daily and Allegra OTC daily PO for his allergies. Maternal grandmother is 51 years of age and has PMH of HTN and GERD; Maternal grandfather diseased secondary to MVA 3 years ago. Paternal grandmother has not PMH; Paternal grandfather has a PMH of asthma, GERD and Obesity he is under the care of a pulmonologist with good asthma control.
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| Social History: The child lives with both his parents. The mother denies using tobacco, alcohol or any illicit drugs. The mother is a stay at home mom, the father is employed full time as a UPS delivery driver and provides full support for the family. The mother reports that their neighborhood is safe, and is composed of mostly young families.
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Pediatric SOAP Note: Yenixis Martinez-Castillo
REVIEW OF SYSTEMS
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| General: Denies weight changes, changes in appetite. No chills, night sweats, fatigue or changes in energy levels. | Cardiovascular: No chest tightness, chest pain, palpitations. No signs of edema or orthopnea |
| Skin: Normal and healthy skin with no lesions, itchiness or rashes. | Respiratory: No wheezing, shortness of breath, or coughing. No history of pneumonia.
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| Head: Normocephalic with equal distribution of hair. Denies any physical injuries to the head.
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Breast: No bumps, lumps, skin changes or nipple discharge.
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| Eyes: Denies noticing double or blurry vision, changes in visual acuity or excessive tearing or blinking.
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Gastrointestinal: Denies noticing any bloody vomits, swallowing difficulties, indigestion, nausea, hiccups, appetite loss, pain or sensation of abdominal inflation. She also denies jaundice, constipation or diarrhea.
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| Ears: Denies noticing ear discharge, earache, pulling or tugging at ears, ringing in ears or changes in hearing acuity.
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Musculoskeletal: No back pain, joint stiffness, pain or swelling. No fractures.
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| Nose/Mouth/Throat: Denies noticing any dental diseases, allergies, sinus problems, nasal congestion or bleeding.
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Neurological: Denies syncope, transient paralysis, seizure, weakness or sleeping difficulties.
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| Genitourinary/Gynecological: Denies any changes in the color of the urine, no urgency or frequency burning.
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Heme/Lymph/Endo: Denies any history of blood transfusion, swollen glands, night sweats, cold or heat intolerance, increased hunger or increased thirst.
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| Developmental Problems: No development problems reported. | Behavioral Status/Psychiatric: Very active and playful, Enjoys the company of other children his age. No anxiety or depression reported. Denies nightmares or night terrors.
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Pediatric SOAP Note: Yenixis Martinez-Castillo
| OBJECTIVE
KINDLY ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER |
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| Weight: 33Lbs | Temp: 98.4 | BP: 99/62 |
| Height: 40.5” | Pulse: 78 | Respirations: 22 |
| General Appearance & parent?child interaction: The patient is well oriented in an upright position, alert, quiet, pleasant and well groomed. He appears hydrated and well nourished. His interaction with the mother and medical staff is pleasant and cooperative.
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| Skin: Pink, warm, clean and moist skin with no rashes, lesions, moles or lacerations.
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| Head: Normocephalic with equal distribution of hair, no signs of infestations, no masses, lesions, or tenderness.
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| Eyes: Pupils equal, round and reactive to light and accommodation; extraocular movements intact, no disconjugate gaze, no itching, redness or tearing. Conjunctivae pink and moist.
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| Ears: Intact auditory meatus with no redness, tenderness, drainage, lesions or masses. No pain on palpitation. Passed the whisper test bilaterally.
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| Nose: No septal deviation. Nares patent without lesions, masses or irritation. Pink nasal mucosa, well moistened.
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| Throat/Mouth: Oral cavity pink, moist and free of lesions or masses. The teeth are in good repair, gums are pink without redness or swelling, no bleeding noted. The oropharynx cavity is pink, moist and free from exudates or drainage, no swelling noted. Uvula is midline and rises evenly when saying ahhh.
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| Neck: ROM intact, no weakness, paralysis or stiffness noted. No swollen lymph nodes, masses or lesions. Thyroid gland palpable when swallowing without swelling, pain or tenderness.
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| Cardiovascular: Regular heart rhythm, no murmurs, rubs, gallop or clicks. Palpable Pulses 4+ in all extremities. The capillary refill is less than 3 seconds. No edema noted. No skin areas in extremities with abnormal skin temperature.
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| Respiratory: Lung sounds CTA. Chest is symmetric and rises evenly with respirations. Respiration is even and regular. No intercostal retractions, no use of accessory muscles. No dyspnea on exertion. No nasal flaring or mouth breathing.
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| Gastrointestinal: Abdomen is soft, symmetric and slightly rounded, without pulsation, lesions or masses. Bowel sounds are active in all 4 quadrants. No rebound tenderness or guarding. No signs of constipation or diarrhea.
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| Breast: Breasts are symmetric without masses, dimples, secretions, tenderness, discoloration, drainage or wrinkling of the breasts.
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| Genitourinary: External genitalia skin intact, no lesions, masses or skin discoloration. No pain or tenderness on palpation. Bladder not distended and non tender. Circumcised male.
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| Musculoskeletal: Full ROM in all extremities, no weakness, stiffness, gait abnormalities or difficulties, no muscular atrophy noted. | ||
| Neurological: Stable balance without gait disturbances or asymmetry, posture is erect. Even muscle strength in all extremities, sensation intact. Mental status AAO to person, place and situation, unable to tell time, however knows it is day time. Cranial Nerves I-XII intact. Popliteal, radial, and ulnar reflexes intact. Speech is clear, with a normal tone and pitch.
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| Behavioral/Psychiatric: No anxiety or depression noted. Pleasant, and cooperative, playful while being examined.
Pediatric SOAP Note: Yenixis Martinez-Castillo |
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| Pediatric/Adolescent Assessment Tools: The Denver Developmental Screening Test II (DENVER II) is commonly used in clinical practice extensively, as it is easy to learn to implement and score and provides a structured approach in developmental assessment screening for children between 0 to 6 years old. The test is a very important tool in identifying children with developmental delay as per their age requirement (Sabanathan, Wills, & Gladstone, 2015). D.C. Denver II results were normal for his age. He demonstrated fine motor skills as he demonstrated abilities of drawing a circle and a square after receiving a simple demonstration of how to draw the figures. He can also draw a person, including a head, eyes, mouth, legs , hands, and hair (6 parts). He demonstrated knowing most colors shown (red, blue, green, black, white, yellow, orange and even purple) without difficulties or delays. He is able to count to 12 without hesitation or discrepancies. He is able to name some opposites such as small-big, tall-short, hot-cold, and good-bad, his skills of describing simple words (ball, house, dot and table) were accurate. And finally, he demonstrated appropriate gross motor skills for a well developed 4 year old as he is able to hop on one leg, and walk heel to toe in a slow but steady and balanced manner (Sabanathan, Wills & Gladsone, 2015). | ||
| Present Developmental: D.C belongs to the preschool stage of development for children between 3 to 5 years. The child is still learning the aspect of independence such as dressing (zippers and buttons), hair grooming and shoe tying shoes (his mother is teaching him). He seems to be assertive and takes initiatives but is sometimes guilty when he is unable to accomplish tasks or is forgetful of required routines, just as Erikson described the basic conflict of this stage as “initiative vs. guilt” (Jones, & Russell-Fisher, 2018).
Movement: able to stand on one foot for about 5 seconds and can hop perfectly. Hand and Finger skills: able to use age-appropriate scissors and draw several shapes. Emotional and social skills: understand the idea of mine and his and is also friendly. Cognitive: can correctly name familiar colors Language: can answer simple questions including saying his name, age and parents names.
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| Lab and/or Diagnostic Tests:
Healthcare practitioners utilize an array of health assessment and growth and development guides in order to assess a child’s developmental status. (McInerny, & American Academy of Pediatrics, 2017). No specific diagnostic tests or labs were done during the exam; however, the Denver II guide was applied with aim at identifying any possible developmental delays. |
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Pediatric SOAP Note: Yenixis Martinez-Castillo
KINDLY ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER
| DIAGNOSIS |
| Final/Primary Diagnosis (es): Normal and healthy
PLAN: · Return to the clinic after one year for a five-year-old well-child examination and immunization. · Vaccines administered this visit: Dtap, IPV, MMR, Varicella. Child has only been vaccinated for Influenza twice, mother refused Influenza vaccine this season. Education risks and benefits provided, pamphlet given, mother stated she will vaccinate for Influenza next season. · Vaccine administration forms given: Influenza, Varicella, Dtap. · Medication: none · Laboratory tests ordered: none · Diagnostic tests ordered: none · Non-pharmaceutical treatments: none · Patient/Family education and Anticipatory guidance for the next well-child visit (van et al., 2015): Ø Communication and Language Skills: strings four or more words together to construct a sentence. Ø Movement and Physical Development: try to walk upstairs and downstairs with alternating feet. Try to catch a ball with both arms fully outstretched. Ø Social and Emotional Development: give the name of one or two of your friends. Name a game liked by your friend. Ø Cognitive Skills: knowing your first and last name, and your age. Take part in pretend play. · When to see a Doctor: all children develop at their own pace, however, current guidelines help in guiding appropriate child growth and development (McInerny, & American Academy of Pediatrics, 2017): ü Teaching provided to seek medical attention if child is unable to speak or construct a full sentence, has severe anxiety or depression or is unable to make strokes with a pencil or crayon. ü Additionally, if you notice that your child has lost some of the skills that he once had or shows weakness on one body side, seek medical attention immediately (Hagan, Shaw, & Duncan, 2017). |
| Self-Evaluation of Interaction with patient/family during clinic visit: I am quite satisfied with the job I did in collecting both subjective and objective data for this well-child visit and immunization update. Despite my strengths in understanding the stages of development and the different milestone, I still find it a weakness to be able to relate appropriately, partially, given my limited experience with the pediatric population. I believe that with more encounters of the same, I will be able to carry out examination and assessment of pediatric patients more efficiently. |
Pediatric SOAP Note: Yenixis Martinez-Castillo
References
Hagan, J. F., In Shaw, J. S., & In Duncan, P. M. (2017). Bright Futures guidelines for health supervision of infants, children, and adolescents: Pocket guide. American Academy of Pediatrics.
Jones, T., & Russell-Fisher, H. (May 11, 2018). Development of a pediatric short-stay observation and assessment unit. Nursing Children and Young People, 30, 3, 20-25.
McInerny, T. K., & American Academy of Pediatrics. (2017). American Academy of Pediatrics textbook of pediatric care. American Academy of Pediatrics
Van, F. I. M. J., te, W. S. C. M., Hartman, E., Elferink-Gemser, M. T., Smith, J., & Visscher, C. (November 01, 2015). The relationship between motor skills and cognitive skills in 4-16-year-old typically developing children: A systematic review. Journal of Science and Medicine in Sport, 18, 6, 697-703.
Sabanathan, S., Wills, B., & Gladstone, M. (May 01, 2015). Child development assessment tools in low-income and middle-income countries: how can we use them more appropriately? Archives of Disease in Childhood, 100, 5, 482-488.