SOAP Note – Wellness Child Exam

SOAP Note – Wellness Child Exam

ID:

Client’s Initials*: T.J. | Age: 6 years | Race: Caucasian | Gender: Male | Date of Birth: 1/1/2018 | Insurance: _________ Marital Status: N/A (Child)

T.J. was brought to the clinic accompanied by his mother. The mother was a reliable historian.

 Subjective:

CC: “I brought him in for a routine check-up and a red rash on his back.”

HPI:

T.J., a 5-year-old Caucasian male, was brought to the clinic by his mother for a routine child health check-up, including a check-up for a rash on his back. The mother reports that she has noticed a red rash occurring on his back in the last four days after his hand visited them after her trip to Indonesia. She reports that T.J. has not shown any signs of itchiness, pain, or discomfort related to the rash. She further notes that he currently does not present any other notable complaints or symptoms that can be attributed to any condition. The mother reports that T.J. has been developing normally and he is in good health. She also notes that he has met all of his developmental milestones for a 6-year-old. He has no recent cases of any illness, injury, or other issue of concern and has not shown any allergies to any foods, medications, or aspects of the environment, both at home and in his current school. T.J.’s mother reports that he is currently attending pre-school classes. She also reports that T.J. has not shown any issues interacting with other children in his class and the play center. She adds that he is active in a normal way for most of the day and enjoys doing activities for his age.

Past Medical History:

• Medical problem list: No reported significant history of medical conditions, including chronic illnesses
• Preventative care: All recommended childhood vaccinations are up-to-date. Reported having a well-child visit a year ago.
• Surgeries: None reported
• Hospitalizations: None reported
• LMP, pregnancy status, menopause, etc. for women: N/A (Minor)

Allergies: Food, drug, environmental: NKDFA

Medications: None

Birth History: The mother reports that T.J. is his second child. T.J. was delivered normally through a normal spontaneous vaginal delivery (NSVD). He was birthed at full term (38 weeks) within the normal weight range for a newborn (weighing 7.3 lbs). He measured 19.6 inches at birth. T.J.’s mother reports that she has no history of smoking or taking alcohol. She was and remained physically active before and during her pregnancy with T.J. She has never been obese or developed any chronic before and during the pregnancy. She also reports that she has maintained a healthy lifestyle post-partum and made sure she attended all of her prenatal and post-natal clinic appointments. She further notes that since she is employed at a family-owned and run business, she had the privilege to take enough work leave to tend to her newborn and be able to breastfeed T.J. for an extended period of 26 months. She also reports that T.J. never showed any feeding and developmental issues during his infancy days.

Family History:

•  Father: 39 years old, physically fit, healthy, no current or history of chronic illnesses.
• Mother: 33 years old, physically fit, healthy, no current or history of chronic illnesses.
• Sister: 9 years old, healthy.
• Grandfather (Paternal): Alive, 66 years old, with hypertension
• Grandmother (Paternal): Alive, 64 years old, no reported chronic illnesses
• Grandfather (Maternal): Died at 56 in an accident, no history of chronic illnesses
• Grandmother (Maternal): Alive, 65 years old, living with diabetes, and currently experiencing symptoms of osteoarthritis

Social History: T.J. is quite a social child although he has down and up times. He loves playing at school, and his teacher has reported him to be brighter than average in his age group. He loves to play with toys, usually heavy machinery toys, since his father works as an industrial operator. He has developed well since joining his current school and has made many friends. His mother reports he is quite the most popular kid among his age mates in his class. He is currently able to select his clothes and dress himself. He does not require assistance with his shoes unless it is tying the shoe laces. He can clearly express himself using longer sentences and is good at copying images from his books.

Sexual history and contraception/protection: N/A (Minor). Both parents have no history of STIs. The mother reports she does not use any contraceptives and protection during sex. She has no extramarital affairs and is sexually monogamous.

Chemical history (tobacco/alcohol/drugs): N/A (Minor). No exposure to tobacco, alcohol, or drugs in the household. T.J.’s mother reports that neither she nor her husband take alcohol, smoke tobacco, or any illicit drugs.

Others:

• Diet: The mother reports that she has focused on feeding T.J. on a balanced diet. She prioritizes actual organic food over snacks. T.J. has adapted to this, and he does not take snacks much.
• Exercise: Mother reports that he is majorly active; he is well engaged at school and plays at school and at home with his sister and friends. Mother believes that he receives enough exercise.
• Sleep: J.’s mother reports that T.J. is a heavy sleeper. She notes that he can sleep up to around 11 hours regardless of whether he has a nap during the day.
• Additionally, the mother reports that she has no security concerns since they live in the countryside and their neighborhood is relatively safe. She ensures that he always wears a seatbelt and sits in the back seat. However, he does not like putting on helmets when riding his tricycle.

ROS

• Constitutional: No recent episodes of fever or other conditions. The child has been healthy and no signs of unintended weight loss or gain were observed. He is typically active and energetic for his age.
• Eyes: No current or history of vision problems, no reported complaints of vision including difficulty seeing, eye pain, or discharge.
• Ears/Nose/Mouth/Throat: No reported issues of hearing. No congestion, no pain or sore throat. No reported mouth and throat issues, including problems with chewing and swallowing. No history of ear or nose infections, child timely responds to his name. No reported changes in voice.
• Cardiovascular: No history of chest pain, palpitations, or known heart conditions. No reported cases of fainting, dizziness, or swelling in the extremities.
• Pulmonary: The child breathes comfortably with no reports of chronic cough, wheezing, or shortness of breath. No history of chronic respiratory infections.
• Gastrointestinal: No reported complaints of nausea, vomiting, diarrhea, or constipation. Reports regular bowel movements, typically once a day, no discomfort with bowel movement. No reports of abdominal pain, bloating, or changes in appetite.
• Genitourinary: No reported issues with urination, including frequency, urgency, or pain. No recent episodes of bedwetting. No reported complaints of discomfort in the genital area.
• Musculoskeletal: No reported muscle pain, joint pain, or stiffness.
• Integumentary & Breast: Red rash on the back, no associated itching or pain. Healthy skin. No history of rashes, lesions, or unusual marks. No history of skin conditions, including excessive dryness, itching, or bruising.
• Neurological: No reported history of headaches, seizures, or other neurological symptoms. Child has hit all developmental milestones as appropriate for his age.
• Psychiatric: Normal mood and behavior for age, no reports of hyperactivity or unexpected moodiness both at home and at school.
• Endocrine: No signs of endocrine issues such as excessive thirst, frequent urination, or growth abnormalities.
• Hematologic/Lymphatic: No history of easy bruising, prolonged bleeding, or anemia. No history of swollen lymph nodes, and there have been no recent infections or illnesses. No reported recurrent infections.
• Allergic/Immunologic: No known food, drug, or environmental allergies.

Objective

Vital Signs: HR: 90 bpm | BP: 98/60 mmHg | Temp: 98.6°F | RR: 22 breaths per minute | SpO2: 98% | Pain: 0/10

Height: 43.4 inches (50th percentile)

Weight: 44.1lbs (50th percentile)

BMI: 16.7 (50th percentile)

Labs, Radiology, or Other Pertinent Studies: None were conducted today.

Physical Exam

General Survey:
Appears a well-nourished, well-developed male child as per current age, alert and active throughout the examination. No o distress.

HEENT: Head is normocephalic, atraumatic. Eyes appear clear, no discharge, conjunctiva clear, pupils are equal, round, and normal-reactive to light and accommodation. Ears tympanic membranes are clear bilaterally, with no discharge, and the nose is clear without discharge. Age-appropriate teeth.

Neck and Throat: Supple, no lymphadenopathy or thyromegaly. Midline trachea no lymph nodes. Normal-sized tonsils without ulcers.

Cardiovascular: HR: 90 bpm/BP: 98/60 mmHg. Heart sounds: S1, S2 regular, no murmurs, rubs, or gallops. No edema was detected.

Pulmonary: RR 22. Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi.

Gastrointestinal: Abdomen soft, non-tender, non-distended, no organomegaly, normoactive bowel sounds.

Genitourinary: No abnormalities noted, genitalia size and shape appropriate for age.

Lymphatic: No enlarged lymph nodes are detected.

Musculoskeletal: Full range of motion in all joints, no swelling or deformities.

Integumentary: The skin is intact, appears red, and has a maculopapular rash localized to the back with minor lesions on the mucus membranes. The rash is non-blanching, non-pruritic, and non-painful. No signs of infection, including warmth, swelling, or drainage around the rash. No other rashes or lesions were noted on the face, hands, and legs.

Neurological: Alert and oriented, normal gait, appropriate reflexes for age.

Psychiatric: Appropriate behavior for age, interacts well during examination. Quite curious.

Assessment

• Routine child health examination without abnormal findings (Z00.129)
• Non-blanching, non-pruritic, and non-painful rash localized on the back

Differentials

1. Unspecified viral infection (ICD-10-CM B09), as characterized by skin rash and mucous membrane lesions. Suspected case of a measles infection based on the presentation (Gans & Maldonado, 2024), and the fact the child had contact with his aunt who had visited Indonesia, a country that is currently among WHO’s listing for continued global measles threat (World Health Organization (WHO), 2023).
2. Contact Dermatitis (ICD-10-CM L23.2) is a possibility based on the presentation of the red rash. However, it is ruled out, noting that the mother denies any known exposures.
3. Pityriasis Rosea (ICD-10-CM L42): It is majorly manifested as a rash patch followed by a generalized rash, often on the back, which is majorly not itchy or painful. However, it is ruled out since there is no patch, and the current rash was full-blown for the last 3 days.

Diagnosis

1. Unspecified viral infection (ICD-10-CM B09)

Plan:

• Diagnostics:

1. Viral Serology Testing with a focus on Measles-specific IgM and IgG antibodies
2. Complete Blood Count (CBC) to determine instance if the patient is immunocompromised and rule out bacterial infection

• Treatment:

1. Keep patient hydrated
2. Have the patient rest for a week
3. If measles is diagnosed: Combined vit A with Ribavirin 400 mg orally twice a day for 5 days

• Education:

1. Discussed and educated mother on the need to keep on taking T.J. for all recommended vaccinations with a focus on how vaccines improve protection against childhood and adolescent diseases and conditions (Drutz, 2024) and to counter the current misinterpretation of the vaccine benefits-risk ratios contributing to caregiver hesitancy and refusal to vaccinate their children (Boom & Healy, 2024).
2. Emphasized the need to continue the child on a balanced diet and physically active
3. Discussed the need for isolation for the patient during the period of medication
4. Mother educated on measles immunization and its importance

• Follow-Up:
  • The mother advised to bring the child back in within the next 72 hours
  • The mother advised to bring the child in in case she has any concerns or questions.
  • Regular follow-up advised on a weekly basis
  • The next wellness check-up is scheduled for the next 6 months or as needed

References

Boom, J. A., & Healy, M. (2024). Standard childhood vaccines: Caregiver hesitancy or refusal. https://sso.uptodate.com/contents/standard-childhood-vaccines-caregiver-hesitancy-or-refusal?search=education+on+need+for+adhering+to+childhood+vaccination+&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

Drutz, J. E. (2024). Standard immunizations for children and adolescents: Overview. https://sso.uptodate.com/contents/standard-immunizations-for-children-and-adolescents-overview?search=education+on+need+for+adhering+to+childhood+vaccination+&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2

Gans, H., & Maldonado, Y. A. (2024). Measles: Clinical manifestations, diagnosis, treatment, and prevention. UpToDate. https://sso.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-prevention?search=viral+exanthem+children&source=search_result&selectedTitle=4%7E41&usage_type=default&display_rank=4

World Health Organization (WHO). (2023, November 16). Global measles threat continues to grow as another year passes with millions of children unvaccinated. https://www.who.int/news/item/16-11-2023-global-measles-threat-continues-to-grow-as-another-year-passes-with-millions-of-children-unvaccinated

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Create a pretend SOAP NOTE CHILD WELLNESS EXAM **Z00.129**: Encounter for routine child health examination without abnormal findings …I attached a sample SOAP NOTE, please do not copy, please create an original but similar to this Please DO NOT use the textbook as a reference. we need to use Clinical Guidelines. You can also use my up-to-date account to find clinical guidelines and treatments. Please make sure plagiarism free and below 20% on TurnitIn

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**Z00.129**: Encounter for routine child health examination without abnormal findings

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