Soap note example well visit

Masterjoe I need a SOAP note fixed. I will up load and example with comment to make it easier to complete. My perceptor also uses bright future so use as much as you can from the example paper and check vaccinations and dosage for weight.

Running Head: TWO YEAR SOAP NOTE Two-year SOAP NOTE 2 YEAR SOAP NOTE Name: K. H Date: 5th SEP 2017 1 TWO YEAR SOAP NOTE Sex: MALE 2 Age: 2 YEARS DOB: 21 JULY 2015 Place of Birth: White Plains- New York SUBJECTIVE Historian: Mother Purpose Well child check up Present Concerns/CC: “the toddler produces clear mucous.” “he is chewing his fingers” “he has a runny nose that has been around for 8 days.” Child Profile The child had had a runny nose for around 3 days clear drainage no fever. He has no weight loss. He has no any sexual history. He has had otitis media of right ear 6 months ago. There are various safety practices on the child. Some of the practices include keeping all the The reasonproducts is given by the from patient seeking medical careof “in quotes.” household away thefor child’s reach. Locking doors in areas where the child might experience serious warms. Removal of furniture with sharp edges within the room of the child or in areas where the child might get in contact with them. Other safety practices include keeping all medicine out of sight and reach of the child. Keeping all medicine caps tight. The development of the child has been normal. TWO YEAR SOAP NOTE HPI: The child has never been critically ill. He had never hospitalized before though he was born prematurely. The victim experiences are swelling within the eyes. There are no major surgeries done at the infant as well as the prevalence of any major traumas. Some of the pertinent positives of normal development include verbal direction following, can recite half his ABC’s and spell his name abit, some clear drainage noted mucus. Upon oral inspection, the child is noted to be cutting a right molar. Pertinent negatives include running nose. Some of the aggregating positives include no coughing, as well as, no colored drainage, no temperature. The alleviating factors include reduced runny nose in when the baby is warmly dressed or does not come into contact with coldness Medications: Acetaminophen- prn every 4 to 6 hours dose acetaminophen based on a child's weight, using 10 mg/kg/dose. Educate parents on proper dosage and lbs to kg conversion age 2 years PMH: Allergies: The child is allergic to cow milk, pollen, and fur Medication Intolerances: K. H has aspirin and antibiotic medical intolerance Chronic Illnesses/Major traumas: The toddler has not had any major traumas or any other cases of chronic illnesses in his health history other than ear infection note 6 months ago Hospitalizations/Surgeries: Immunizations: The child has not had any kind of hospitalizations or major traumas 3 TWO YEAR SOAP NOTE 4 Family History The father of the patient is trying to manage her sugar levels as he has been diagnosed with diabetes. The mother has been having cases of high blood pressure. One of the siblings of the client has been diagnosed with asthma. The other sibling is health with no cases of cancer reported in the family. Social History The baby is active in his day care. No education or occupational history on the patient as he is Only a 2-year infant. The child is living with his two parents and siblings. The parents have a sound financial status, hence able to give the baby the comfort that he deserves. The home is safe with no cases of insecurity in the neighborhood. There no history of alcohol, tobacco, ETOH or marijuana abuse on the child ROS General Cardiovascular The baby appears healthy. Neatly dressed and There are no reported cases of orthopnea, PND or good weight. edema. The palpitations are normal with o cases of chest pains. The heart rate is normal Skin Respiratory There are no bruises, discoloration, moles or No record of wheezing. However, the baby seems to lesions of the infant’s skin. breathe without difficulty TWO YEAR SOAP NOTE Eyes 5 Gastrointestinal No issues in regard to the Gastrointestinal. The No There are no cases of blurred vision or any kind blood spots on the stool of visual changes. There seems to be swelling around the eyes Ears Genitourinary/Gynecological No hearing loss, discharge from the ears or pain. There are no Genitourinary/Gynecological The patient does not experience any kind of complications ringing over the years. Nose/Mouth/Throat Musculoskeletal The nose is runny, producing clear drainage. There are no musculoskeletal complications. No There is no congestion noted within the nose. significant swellings or cases of stiffness The gums are in good condition, red swollon lower right of gum area. No complaints of sore throat Breast Neurological the breasts are in perfect condition The patient does not experience any kind of paralysis, seizures, weakness or black out spells Heme/Lymph/Endo Psychiatric The client HIV status is negative. He has never There are no any psychiatric complications that can be had any kind of blood transfusion. The child is intolerant to low temperatures noted from the client TWO YEAR SOAP NOTE 6 OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight 20 lbs [10.9 kg] Height 2 feet 5 1/2 inches Temp 36.0 temp.scan Pulse 36.5°C 117 beats in a minute BP not need since this child is not 3 Resp years old 28 breaths within a minute General Appearance and parent‐child interaction The baby is oriented and alert. He appears neatly dressed and seems to interact well with the mother. his weight is okay and appears to be well nutritional Skin The skin is clean and intact. The skin is warm with no cases of rashes or lesions. HEENT The patient does not have a history of any trauma in his life. No lesions or moles which can be noted. There seem to be swellings around the eyes. The nose is runny with no prevalence of congestion. The patient is producing clear drainage. No hearing problems or any infections that can be related to the ears. There are no occipital nodes around the neck, and the nose mucosa does not appear pink. The gum seems to be in good condition. The ear canals seem okay Cardiovascular The S2 and the S1 palpitations seem regular with the rhythm being normal. The capillary refills within 2 seconds. No extra sounds which can be noted in the process of breathing with no edema complications seen. The pulse is 3+ TWO YEAR SOAP NOTE Respiratory The chest is symmetric with regular respirations which occur naturally. The auscultations of the lungs appear to be clear with no difficulty in breathing. Gastrointestinal No abdominal obese. There are no cases of abdominal pain.