Pediatric Wellness SOAP Note for 5 year old

write a SOAP note for a well-child annual visit using the template below. and include growth chart. for a 5 year old. initals T.G,  Scholarly references, no older than 5 years old. (Comprehensive SOAP Note on Pediatric Wellness)

Comprehensive SOAP Note on Pediatric Wellness

Subjective:

ID: ID: T.G, 14/1/2018, 5-year-old white female. T.G. is brought to the clinic by the mom. Pt unreliable; the information provided by the mother is reliable. Consent obtained.(Comprehensive SOAP Note on Pediatric Wellness)

CC: “Routine check-up.”

History of Present Illness: T.G. is a 5-year-old white female in for a well-child annual visit. The patient states that she is well. The mom confirmed the statement. The last check-up was a year ago. The patient is up to date with health screening. The last screening was on 17/1/2022. The mother reports that T.G. has a fever and looks sick.(Comprehensive SOAP Note on Pediatric Wellness)

Birth History: The patient is five years as of the present visit. Complete birth history obtained. The patient was born early term (37 weeks) through a cesarean section with no other complications recorded during pregnancy and at birth. The mother denies drug and substance abuse during pregnancy and sought prenatal and postnatal care.(Comprehensive SOAP Note on Pediatric Wellness)

Developmental History

• Milestones (Bright Futures Pocket Guide, 2017):
  • One month – Looks at the parent, brings a hand to mouth, looks at objects briefly, alert to sounds, sensitive to the environment, moves all limbs, holds chin up on the stomach, slight opening of fingers at rest,
  • Two months – Smiles responsively, makes cooing sounds, lifts head and chest, opens and closes hands.
  • Four months – Laughs, turns to voices, rolls over, supports self on risk/elbow, keeps hands open, and grasps objects.
  • Six months – Turn head towards a sound, respond to her name, babbles, sit for a short time without support, and pass objects from one hand to another.(Comprehensive SOAP Note on Pediatric Wellness)
  • Nine months – Holds arm out to be picked, looks around for sounds, makes steps without support, crawls, and picks up food to eat.
  • Fifteen months – Scribbles, runs, points to ask something, speaks in sounds (unknown), drops and picks objects.
  • Eighteen months – Plays with others, undresses self, points to things on T.V. and pictures in a book, identifies the head and eyes, sits in a chair, and throws objects.
  • 2 Years – Plays with other children, removes clothes win some help, combines words, names various body parts, jumps off the ground, and runs.(Comprehensive SOAP Note on Pediatric Wellness)
  • 5 Years – Sometimes urinates on a potty, uses phrases, draws lines, and runs steadily. Stands on one foot and brushes teeth with the help of another person
  • Three years – Uses potty well, removes and puts on clothes by herself, compares things, climbs up and down chairs, pedals tricycle, and draws.
  • Four years – Sing alongside familiar songs, takes off and put on clothes, answers questions, draws recognizable pictures, follows simple rules, stands and skip on one foot, and climbs chairs with alternating feet.(Comprehensive SOAP Note on Pediatric Wellness)

Past Medical History: No history of tonsillitis or injuries.

Past Surgical History: None

Medications

• Desitin Creamy Ointment OTC was last used two years ago.
• Vaccinations (S. Department of Health and Human Services (DHHS), Centre for Disease Control and Prevention (CDC), American Academy of Family Physicians (AAFP),& American Academy of Paediatrics (AAP), 2022)
  • Hep B – 14.1.2018, 14.2.2018, 14.3.2018
  • RV3 – 13.3.2018, 14.5.2018, 13.7.2018
  • Dtap – 12.3.2018, 13.5.2018, 12.7.2018, 14.4.2019
  • Hib – 14.3.2018, 12.5.2018, 14.7.2018, 14.1.2019
  • PCV13 – 13.3.2018, 10.5.2018, 12.7.2018
  • IPV – 14.3.2018, 12.5.2018, 15.7.2018, 14.1.2019
  • IIV4 – 13.1.2019, 14.1.2020
  • OR LAIV4 – 13.1.2019, 14.1.2020
  • MMR – 15.1.2019, 10.4.2019
  • Varicella – 14.1.2019, 15.4.2019
  • Hepatitis A – 15.1.2019, 14.7.2019

Vaccine	At Birth	1 Month	2 Months	4 Months	6 Months	12 Months	15 Months	18 Months	2 Years
Hepatitis B ( hep B) –	14.1.2018	14.2.2018	14.3.2018
Rotavirus(RV): RV1 (2dose series) RVS (3-dose series)			13.3.2018	14.5.2018	13.7.2018
Dtap <7 yrs			12.3.2018	13.5.2018	12.7.2018		14.4.2019
Haemophilus Influenzae type b (Hib)			14.3.2018	12.5.2018	14.7.2018	14.1.2019
Pneumococcal conjugate (PCV13)			13.3.2018	10.5.2018	12.7.2018
IPV < 18 yrs			14.3.2018	12.5.2018	15.7.2018	14.1.2019
Influenza (IIV4)						12.1.2019			14.1.2020
OR LAIV4						13.1.2019			14.1.2020
MMR						15.1.2019	10.4.2019
Varicella						14.1.2019	15.4.2019
Hepatitis A						15.1.2019		14.7.2019

Allergies: Reports history of diaper dermatitis.(Comprehensive SOAP Note on Pediatric Wellness)

LMP: N.A.

Family History

	MOM	DAD	SISTER	BROTHER	MGM	MGF	PGM	PGF
DIABETES		✔			✔
HTN							✔	✔
HLD						✔		✔
ASTHMA				✔	✔
CARDIAC					✔			✔
AGE OF DEATH					55	63

Social History: Lives with the mother. Parents are separated. The patient likes cycling. Spends time playing with older brother and sister in the backyard during the evening or holidays. T.G. began kindergarten three months ago. Taken to and from school by school bus. Relates well with peers at home and school. He is active in school. Loves yogurts. Sleeps 10 hours/24 hours.(Comprehensive SOAP Note on Pediatric Wellness)

REVIEW OF SYSTEMS.

General: No weight gain or significant illness history.

Skin: Normal skin turgor and pressure. No acne was observed.

HEENT: Head: No head injury, good vision, no cataracts. Ear: No ear infections. Has appropriate hearing ability. Nose: Clear nasal passage. Throat/ Mouth: Routine teeth brushing. No cavities. Tonsils laterally in the pharyngeal. Neck: No neck swelling or lumps.(Comprehensive SOAP Note on Pediatric Wellness)

Respiratory: Normal breath sounds. Normal chest expansion. No shortness of breath or wheeze was noted. Clear lungs. 

Cardiovascular: No abnormal heart sounds. No murmurs. Regular femoral pulses.

Gastrointestinal: No masses or tenderness. The abdomen is soft and non-distended. Normal liver margins and non-tender. Non-palpable kidneys and spleen. All bowel sounds are present.

Genitourinary: Clear yellow urine. Denies signs or symptoms of UTI. No retention, no frequency, no burning when urinating.

Musculoskeletal: Full range of motion in upper and lower extremities. Normal range of joint motion. No kyphosis, lordosis, or scoliosis. Normal gait.(Comprehensive SOAP Note on Pediatric Wellness)

Neurologic: Reports headache and fatigue. No seizures.

Psychiatric: T.G. looked dull but well-adjusted. Normal memory and insight.

Immunologic: The last allergy was reported two years ago.

Lymph: Swollen lymph glands and painful neck.  (Comprehensive SOAP Note on Pediatric Wellness)

Endocrine: No history of cold or heat intolerance. No excessive sweating or thirst. No complaints of excessive hunger.

Hematology:  No ease of bruising or bleeding noted. No history of blood transfusions. No blood in the urine.

OBJECTIVE

• Vitals Signs: H.R. 87 bpm, regular. B.P. 100/55 R.R. 23           97%        Temp 37.8 C
• 39.3in WT in Kg: 16           BMI: BMI = 16 kg/m²   (72%, Healthy weight)                                                   

Growth Chart

General Survey: T.G. is a lovable 5-year-old male who appears healthy. 

Skin: Normal skin turgor and pressure. No acne was observed.

HEENT: Head: No head injury, good vision, no cataracts. Ear: No ear infections. Has appropriate hearing ability. Nose: Clear nasal passage. Throat/ Mouth: Routine teeth brushing. No cavities. Tonsils laterally in the pharyngeal. Neck: No neck swelling or lumps.

RESPIRATORY: Normal breath sounds. Normal chest expansion. No shortness of breath or wheeze was noted. Clear lungs.  

CARDIOVASCULAR: No murmurs or abnormal heart sounds. Regular femoral pulses.

GI.: No masses/tenderness, soft, and non-distended. Normal liver margins and non-tender. Non-palpable kidneys and spleen. All bowel sounds were present.(Comprehensive SOAP Note on Pediatric Wellness)

GU: No signs of UTI. Clear yellow urine. No urine retention, frequency, or burning sensation.

MUSCULOSKELETAL: Full range of motion in upper and lower extremities. Normal joint movement. Normal gait. No kyphosis, lordosis, or scoliosis was noted.(Comprehensive SOAP Note on Pediatric Wellness)

NEUROLOGIC: Headache. No seizures. Weakness reported.

DIFFERENTIAL DIAGNOSIS

1. Well-Child, ICD-10 Z00.129
2. Tonsillitis, ICD-10 J35.9
3. Immunizations, ICD-10 Z23

PLAN: Start Penicillin V 25 mg/kg q6h for ten days. Penicillin is FDA Indicated for group A streptococcus bacteria associated with the development of tonsillitis and is effective in treating the condition in children (Ståhlgren et al., 2019).  (Comprehensive SOAP Note on Pediatric Wellness)

Evaluate social health determinants – Risks, strengths, and protective factors (Bright Futures Guidelines, 2017).

EDUCATION: Appropriate diet for the child and maintain a healthy weight. Maintain hygiene. Drink at least 2 to 3 daily to remain hydrated. Encourage routine screening. The parent should teach the child non-violent conflict resolution methods, maintain safety belt regulations, encourage independence, and show affection and praise when necessary (Bright Futures Guidelines, 2017).

FOLLOW-UP: After one week for tonsillitis and after one year for a well-child exam.

REFERRAL: Refer to a pediatric dietician for an appropriate diet.

References

Bright Futures Pocket Guide (4th ed.). (2017). American Academy of Pediatrics. https://www.aap.org/en/practice-management/bright-futures/bright-futures-materials-and-tools/bright-futures-guidelines-and-pocket-guide.

U.S. Department of Health and Human Services, Center for Disease Control and Prevention, American Academy of Family Physicians, American Academy of Pediatrics. (2022) Recommended Immunizations for Children from Birth through 6 Years Old. Available at: https://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf

Ståhlgren, G. S., Tyrstrup, M., Edlund, C., Giske, C. G., Mölstad, S., Norman, C., … & Hedin, K. (2019). Penicillin V four times daily for five days versus three times daily for ten days in patients with pharyngotonsillitis caused by group A streptococci: randomized controlled, open-label, non-inferiority study. BMJ, 367. https://doi.org/10.1136/bmj.l5337