Name: HB Date: 6/19/19 Sex: Female Age/DOB/Place of Birth: 3yrs/5-22-18/Greenville, NC SUBJECTIVE Historian: Mother Present Concerns/CC : “Well child visit” Child Profile : Pt is a healthy appearing 3year old Caucasian female. The mother states her overall health is good, she is very active and playful. She reports no chronic illnesses, no speech or growth delays. She talks well and speaks in sentences. Mom reports no previous injuries that have required medical attention. She states in general she is a pleasant child, eats a well-balanced diet, drinks water in-between meals and milk with meals. She sleeps in her own bed at night and sleeps approximately 8-10 hours every night. HPI: 3-year old child accompanied by mother presents to clinic for a routine well child visit. The patient has no previous medical history requiring treatment or chronic care. The child is alert and sitting in mother’s lap. Pt appears well nourished, well behaved and well groomed. Medications : None PMH: Pt was a planned pregnancy with prenatal care beginning at approximately 10 weeks gestation. Mom was healthy during pregnancy, she did not smoke, consume alcohol or illegal drugs. She reports no illness during pregnancy. The only medications she took was a daily prenatal and folic acid. She had a 40-pound weight gain during pregnancy, delivered vaginally with no complications. Child is healthy with no reported illnesses or infectious diseases. Allergies: NKA Medication Intolerances: None Hospitalizations/Surgeries: No surgical history or hospitalizations reported. Immunizations: Up to date Family History Mother, 28, Healthy Father, 27, Healthy Sister, 5, Healthy Pediatric SOAP Note
Social History Mother is currently separated from the child’s father. Child resides with mother but goes to see father every other weekend. Mother reports no one smokes around child. Mother currently works as an elementary school teacher, Ls attends daycare while she works. Mom denies alcohol or substance use by her and by biological father. Mom reports she has never been abused physically or sexually and feels safe in her home and community. ROS General Mother reports the child is playful and active, has a fair appetite but can be picky at times. She consumes about 18 ounces of milk daily with meals and drinks water between, occasional juice intake. Mom denies any fever, weight changes, recent illness or sleep issues.
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- Summer '17