Assignment: Soap Note

Present Concerns/CC:  “I’m here for the check up for his 6 moths”

This is 6 months old female infant that was brought for her mother. Information was provided by the mother. Per Mom she breastfed her for about 5-6 times daily mother state that she introduced a new element to her diet that is puree that is home made. Mom state that patient has 1-2 bowel movements daily and an average of 9-10 wet diapers. She sleeps 8-10 hours at night and takes 2 naps of approximately 1-2 hours during the day. Mother and grandmother split the time caring for her at home due to Mom work part-time now. Patient is able to move front to back and back to front and sits well with slight support. Patient responds to mother’s voice, giggles, and babbles. Per mother, patient is not exposed to second hand smoking, rides on the back of the car with car seat facing backwards. No guns or pets at home and patient is kept in a hazard free environment.

This is 6-month-old female who presents with mother for her 6-month well-visit checkup. No past medical history or current health concerns

None

Allergies:  NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: up today

Mother- 25 years old. Alive and well

Father- 29years old. Alive and well

Grandmother :55 ,HTN ,Alive

Patient lives with mother and grandmother, she is single Mom. Mother and grandmother caring for the child, Mom work as teacher part-time. Mother denies smoking, guns, pets, or violence at home.

Denies for fever, lethargy, difficulty arousing or irritability

Denies for cyanosis, swelling or activity intolerance

Denies rashes, urticaria, lesions or birthmarks

Denies cough, difficulty breathing or wheezing

Denies strabismus, eye irritation or discharge

Denies decreased appetite, reflux, burping or diarrhea

Denies for ear tugging or discharge

Denies for anuria, changes in color of urine or discharge

Denies nose congestion, nose bleeds, or mouth sores

Denies for fractures or contractures

Denies for lumps

Denies syncope, seizures, epilepsy or tremors

Denies blood transfusions, inability to growth, or sweet odor of urine or sweat

Denies difficulty falling asleep or staying asleep

15 lbs

26 inches

SpO2: 99% at Room air

Well- nourished, healthy looking patient held in arms by mother. Both look happy.

Skin is warm to the touch and dry. No rash, lesions or bruising.

Head: Normocephalic head, oval shape and no traumas. Closed posterior fontanelle.

Eyes: Pupils PERRLA. Present red reflexes on both eyes

Ears: No tenderness. Pink tympanic membranes

Nose: Normal turbinates. Septum midline

Mouth: 2 bottom central incisors.

Throat: No erythema of exudates

Neck: Supple without masses or thyroid enlargement