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Well Exam Child Soap Note

Name

United State University

Primary Health of Acute Clients/Families Across the Lifespan-Clinical Practicum xxx

Professor

Date
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SUBJECTIVE

ID: .J. L, Age: 9, Race: African American, Gender: Female, Date of Birth: January 15, 2013,

Insurance: N/A

CC: "my annual wellness visit was scheduled today so I came for check up."

HPI: J.L is a nine-year-old girl who comes to the facility accompanied by her caregiver for

her yearly health assessment. The client is in for her yearly assessment and has no serious

health problems at the moment. The client responds appropriately to concerns and seems to

be in good health. she lives with her parents, and her two brothers . Her most previous health

test was on January 5, 2021, and she was found to be in good condition..

PAST MEDICAL HISTORY: She was diagnosed with pneumonia in July 2021, and was

treated with amxicillin. She has nt had any surgeries.

CURRENT MEDICATIONS: None.

IMMUNIZATION: She has had all indicated vaccines given at her age, namely Tdap, Human

papillomavirus vaccine, rubella, meningococcal, MMR measles, pneumonia, hepatitis A & B,

Polio, and mumps.

PREGNANCY AND BIRTH HISTORY: Mother asserts that she never consumed illicit

drugs, smoked tobacco, or drunk alcohol. She reported that the child was  delivered through a

spontaneously vaginal delivery at 38 weeks and managed to nurse without issue.

Developmental History: The child, as per her mother, fulfilled all normal age-related stages

on schedule.

FAMILY HISTORY: Both of the child's guardians are living and well. The dad is 40 years

old and has a pollen allergy. The mom, who is 35 years old, has high blood pressure that she

treats with a healthful lifestyles and Losartan 25mg PO. The client has 4-year-old twin boys

who are in good health and have no illness experience. The paternal grandmother of the child

is 70 years old and has rheumatism. To treat the problem, the grandma used nsaids. The
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paternal grandpa has slight cognitive impairment and is 74 years old. His memory is fading

him, and he is experiencing trouble recalling prior occurrences. He's been going to treatment

to improve his cognition..

SOCIAL HISTORY: Her father, mother, and little brothers live alongside her. She attends a

nearby high school. She enjoys acting and aspires to be a physician when she is grown up.

Helen is a classmate with whom she attends school. Both like singing and are now enrolled in

a music class. Cakes and juice are her favorite foods.

DIET: The client professes to eat red meat thrice each week, adores cake and sweet

beverages, and hates veggies. She does, nevertheless, claim to consume an orange at least

once a day.

SLEEP/STRESS: She rests for at minimum of nine hours and gets to rest around 8:30 & 9:30

p.m.

SAFETY: Whenever pedaling a bike or scooters, the client wears protective equipment like

as a helmet and knee pads. She occasionally uses a seatbelt while traveling in a vehicle.

SPIRITUALITY: Christian

REVIEW OF SYSTEMS

GENERAL: The patient objects to the following symptoms: high temperature, weight gain,

excessive sweating, hunger changes, loss of weight, poor activity endurance, and exhaustion..

HAIR, SKIN, AND NAILS: She denies havig changes in skin pigmentation, sunburns,

lesions or rashes.

HEAD: She denied having migrains, blurrig vision, erythema, pain, or eye drainage.

NECK: She denies neck stiffness, or pain.

EYES: She denies eye discharge, pain or blurred eye sight. She denies using corrective

lenses.
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EARS: No bleeding reported. She denied hearing loss,vertigo, ringing in the ears, or

discharge.

NOSE: She denies post nasal drainage, nose bleeding and nasal congestion. Throat: she

reports no concerns with swallowing. No sore throat reported.

CARDIOVASCULAR: she denies peripheral edema, palpitatins, or chest pain.

GASTROINTESTINAL: she reports no abdominal pain. She denies diarrhea, nausea and

vomitng.

PULMONARY: she denies breathing difficulties, coghing or wheezing.

LYMPHATICS: she denies having tender or swollen lymph nodes.

GENITOURINARY: she denies painful urination, increased frequency or urgency in

urination.

HAEMATOLOGICAL: she denies pathologic blood clots, or excessive bleeding.

MUSCULOSKELETAL: no mucle or joit pain reprted.

NEUROLOGICAL: she denied memory problems, headaches or blackout spells.

PSYCHIATRIC: she denied extreme mood swings, or depression.

ALLERGIC: she sneezes in pollen tobacco and.smoke

OBJECTIVE

VITAL SIGNS: B/P 106/74; HR 78; RR 20; Temp 98.8 F; BMI 24 kg/m², Wt 79 lb , Ht 4.0".

SpO2 99%,

PHYSICAL EXAMINATION

GENERAL APPEARANCE: she is well dressed. She s nt in any distrees and appears to be

happy

HEENT: Normocephalic. Atraumatic. Eyes:accommodation is normal. Conjunctiva is free

from erythema. Tere is no evidence of abnormal tearing. Ears: the tympanic membranes are

free from inflammation. No discharge was noted. Nose: Noseptal deviation , drainage noted.
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NECK: it is supple, and flexible. Cervical lymph nodes are normally sized.

ABDOMEN: the abdomen is soft ad non-teder. Bowel sounds are present in the four

quandrants.

RESPIRATORY: respirations unlaboured and rate is within normal range.

CARDIOVASCULAR: capillary refill is tw seconds, heart rate, blood pressure are normal

GENITOURINARY: she denies costovertebral angle tenderness, vaginal discharge. Denies

havig menstruation.

SKIN: the skin is intact and free frm bruises.

MUSCULOSKELETAL: spine curverture is normal. No jint pain r inflammation ticed.

NEUROLOGIC: No paralysis reprted. No facial drooping noticed.

PSYCHIATRIC: she is oriented. No evidence of irrational thinking.

ASSESSMENT

DIFFERENTIAL DX:

Wellness Exam:. A young female who turned up for a physical examination. Monitoring

need be performed at regular clinic appointment for regular developmental assessment, as per

the American Academy of Pediatrics.

Other nonmedicinal substance allergy status:. Client has a smoke and pollen allergy, as

demonstrated by sneezing, watery, itchy, and red eyes.

Dietary surveillance and counseling: Healthy foods help a child's proper growth as well as

maturation. A kid must be given nutritios meals in adequate serving quantities as

recommended by the CACFP. Fruits, dairy, cereals, grains, veggies, or meat optios should all

added in the dishes. Furthermore, the youngster must be trained healthfull dietary behaviors.

Sugary drinks and smoothies need to be shunned at all times.

PLAN
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CBC for a general health check Annaul well exam to check on vaccinations, growth, and

safety concerns

EDUCATION: The client was recommended to adopt a good lifestyles by consuming enough

of fluids, fruits and vegetables, nutritious grains, fat-free and low-dairy dishes. A vast range

of foods rich in protein, and healthful oils obtained from fishes and veggies (Goolamally et

al., 2019). Furthermore she was encouranged to cosume foods rich in calcium to maintain

healthy and strong bones healthy. To prevent a drowning incident, inform the client the

importance of keeping an expert monitor them throughout all swimming occasions. Instruct

the parents to pursue immediate clinical aid when the child develops substantial difficulty

breathing or any other indications of an icreased allergy.

After a fortnight, follow up to address nutritional modifications that would assist the kid

retain a desirable bodyweight and prevent obesity.

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Reference

Goolamally, N., Hamid, S. A., Ramli, A. Z., & Rahim, R. A. (2019). Application of rasch

model in measuring the quality of health and wellness final exam questions.