Breast: No masses, lesions, tenderness, or discharged noted. No dimpling or discoloration of skin Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note noted . Genitourinary: No CVA tenders. Tanner stage I. Uncircumcised, testes descended bilaterally. Musculoskeletal: ROM intact, no difficulties. No signs of congenital hip dysplasia. Ortolani and Barlow maneuvers are negative. Neurological: AAOx4. Calm. Cooperative. Spine midline, no difficulties with ROM. Posture, tone and activity level are within normal limits for age. Behavioral/Psychiatric: Alert. Pediatric/Adolescent Assessment Tools: HEADSS- H- Home- Lives at home with mother, father and siblings. Never home alone. E-Education- Stays home with mother. A-Activities- Eat, Sleep, Pee, Poop and Grow. D-Drugs- No illicit drug usage S-Suicidality- Happy, calm. S-Sex- No sexual contact. Present Developmental: Child developmentally appropriate. Lab and/or Diagnostic Tests: None Immunizations: None DIAGNOSIS Instructions: Final/Primary Diagnosis (es): Z00.110 Routine Child Health Exam Classified as any well child exam for a child under 8 days old. R01.1 Cardiac Murmur- Grade 1 systolic murmur heard on left sternal border. L40.1 Generalized Pustular Psoriasis- Pustules in groin PLAN: Medication: none Pharmacological treatments: None Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note Non-Pharmacological treatments: Discussed findings with parent. Discussed nutrition, sleep, safety, development, feeding schedule, feed on demand, may continue to supplement with formula if needed. Ensure adequate wet and dirty diapers. Referral to cardiology for murmur. Recheck pustules and culture in 1 week. Follow up: In 1 week for groin check. Vaccinations: None (Stead,2019). (American Association of Pediatrics, 2017). Self-Evaluation of Interaction with patient/family during clinic visit: This well child check went very well. The mother was responsive and interactive with me. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note References: “Clinical Practice.” Clinical Practice , 2017, - practice/Pages/default.aspx. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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- Summer '17
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