Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using the Pediatric SOAP Note template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Dropbox. When submitting your note, be sure to include the reference number from CORE.

  Historian: Mother

Present Concerns/CC:

“We have an appointment today for my daughter wellness checkup and update immunizations.”

MR is a Fifteen years old Hispanic female patient who comes to the clinic today accompanied by her mother for a routine wellness annual exam and immunizations. MR lives with her biological parent’s and was delivery through a normal vaginal birth, and the pregnancy was full term without complications. MR does not have a history of chronic diseases, reports feeling well since the last consult and have proper growth and developmental state. The patient states that she sees her periods every month and they last for three days and denies any sexual activity. Patient’s mother inquires about what vaccines the child needs at this time.

MR is a 15 years old teenager brought to the clinic today by her mother for her annual wellness exam. Pt’s mother denies any child history of chronic disease, complication or any concern at this time. The mother reports no previous injuries that have required medical attention and update immunizations.

Tylenol 500mg every eight hours as need it during menstrual periods.

Ø  Allergies: NKA reported

Ø  Medication Intolerances: None

Ø  Chronic Illnesses/Major traumas: no reported

Ø  Hospitalizations/Surgeries: hospitalized for two days due apendicectomy five years ago.

Ø  Immunizations: Up to date

Both parents are alive and healthy. Mother 35 years old without Hx of any disease and father 38 years old, Obese. Pt has a little sister age five who is active and healthy as well. Pt grandparents are alive and suffer from some chronic diseases like Maternal grandmother has COPD and hypertension, and maternal grandfather is recovering from CVA. The paternal grandmother and father are healthy since now.

The teen lives with both parents in a nuclear family with good social/financial status. None of the parent’s smoke or consumes alcohol or any drugs. The patient reports that she is not sexually active and is attending high school with good grades. Pt denies the use of recreational drugs. The patient has a great support system from the parents and the rest of the family. Pt states that have excellent communication with her mother.

Pt well nourished very healthy who has good growth and development for her age. No weight changes. No fever, fatigue, chills, night sweats, or lethargy.

Patient denies any history of murmur or cardiac issues, no edema, or orthopnea at this time.

Denies delayed healing, rashes, eczemas, lumps, bruising, itching, dryness, bleeding or skin discolorations, any changes in lesions or moles.

.

Negative for dyspnea, cough, wheezing, or tachypnea

Symmetric. Parent denies eye redness, or drainage.

Negative for nausea, vomiting, diarrhea or constipation.

Patient denies ear pain, or problems with hearing or discharge.

Denies urgency, frequency, burning sensation during urination, and change in color of the urine. No vaginal discharge

pampers.

No symptoms of nasal discharge, congestion, nose bleed, sinus pain, post nasal drip, difficulty in swallowing, and mouth ulcers

Negative for back pain. Denies joint swelling, stiffness or pain, fracture history.

Patient denies breast tenderness and lumps.

Alert and orient in time, place and person. Good psychomotor development for her age. No history of seizures and other neurologic alterations.

Negative for bruising, blood transfusion history, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.

Denies sleeping difficulties, or any previous psychiatric disease. Doing well at school. Good attention span.

Height: 155cm

Weight:110 Pounds

BMI:20.8

 Growth Chart (Between 50-75 percentile (61th)

Teen appears to be well-nourished, in no distress. Cooperative for the exam, interacting appropriately with examiner and mother. Normal weight, healthy, well-developed, alert and oriented, on no distress. Well groomed, pleasant, answers questions appropriately.

Skin is appropriate for ethnicity; warm, dry and intact. Negative of rashes or lesions. Good skin turgor

on examination.

Head: Normocephalic, no traumatic and no lesions noted; hair is uniformly distributed.

PERRLA, Normal conjunctiva and sclera. Pupils are responsive to light and extra ocular movements intact. Funduscopic exam shows no papilledema. No history of dental caries. Ears: External appearance is normal with no swelling or lesions.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

noted. No cyanosis, no clubbing.

Good respiratory pattern. Bilaterally clear to auscultation without rhonchi, crackles, wheezes or

rales. No dullness on percussion, good excursions

Abdomen soft, non-distended and non-tender to palpation. No guarding or rigidity, no masses are present. A little scar of two cm in right lower quadrant (appendectomy).

Symmetric, normal in texture and skin color, no nipple discharge. No presence of mass and pain

during examination. Tanner stage like adult.

Menarche at 12, sees period regularly and last for around three days. All secondary

sexual characteristics present, Tanner stage: adult like, fully developed breast and pubic hair.

Pt reports she is not sexually active. No lesions to external genitalia noted.

Rectal exam: Differed.

No joint deformities. Bilateral upper and lower extremities equally and with normal configuration. Normal Full ROM in all extremities as patient moved about the exam room.

Alert and oriented x 4. Speech clear. Cranial nerves II to XII intact. Good tone. Posture erect. Balance stable; gait normal.

Dressed clean and appropriately. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Done in Office:

1.     Snellen chart OU=20/20, OS=20/20, OD=20/20.

2.     Normal hearing

3.     Random glucose test (88mg/dl).

4.     Hb 12.6 mg/dl

5.     Urine dip test: Negative.

No need for further testing at this point.

No diagnostic tests were ordered during this visit.

HEADSSSVG Assessment for adolescents was conducted and no evidence of depression was found.

1- Primary diagnosis (Z00.129): Encounter for routine child health examination w/o abnormal finding

2- Differential diagnoses: N/A

Vaccine administration forms given

Education: The parent should keep closed communication with the teen all over so that they be able to note any changes to their well-being with no trouble. They should also provide proper training and guidance to the child on the probable diseases that can affect them in the last phases of life so that she will be better prepared psychologically and able to handle it successfully. We should not forget that educate the child on safety is vital, and the security actions should be efficiently spoken to the child to prevent any damages that can negatively affect their health. Also, it is essential to maintain a healthy diet which will help with the proper growth and will prevent obesity which has been changing the children leading to diseases as HTN and Type II DM. Though this Pt. is adequately vaccinated according to schedule, is also essential to enforce the importance of vaccination in the prevention of transmissible diseases and its complications.

Anticipatory Guidance: Parent should be advised that they must keep closed attention to the adolescent mood as sometimes depression goes unnoticed and suicide is one of the most common causes of death at this age altogether with accidents and drug/ETOH use and abuse.

Follow up/Referrals: No referrals needed at this time.