Soap Note Well-Adolescent Visit

Initials: C.R.

Age: 13 years old.

D.O.B: 09/17/2005.

Gender: male.

Race: Caucasian.

C.R. came with his mother.

Subjective:

Chief complaint: “I came for a well visit.”

History of present illness: C.R. came for his well-child examination. The patient does not have any complaints.

Home: C.R. lives with his parents and older sister of 15 years old. Parents are married for 16 years and live in a three-bedroom private house.

Diet: C.R. has a good appetite. He eats regularly, mostly home-made food. He eats three-four times a day. He drinks water, juice, milk, and tea. C.R. does not calculate the amount of liquid consumed. His mother is housewife, and she cooks. The family prefers healthy food. C.R. stated that he likes eating sweets and fast-food occasionally.

Dental care: C.R. informed that he brushes his teeth twice a day after food. He sees a dentist twice a year.

School: He studies at 8th grade at community school as well as gets only A and B grades.

After school: C.R. comes home after school, has a dinner, and does his home task or conducts other activities.

Safety: Mother states that they do not have guns or dangerous substances at home. Moreover, they live in a not dangerous community. His mother watches C.R. to use seat bells always.

Activities: C.R. likes cycling with friends when weather is warm. He visits swimming lessons twice a week. He likes playing soccer with friends occasionally. He walks 3.5 miles daily when goes to school and back on foot.

Social: The boy is socialized. He is not very sociable but have several close friends. He participates in class activities and meets his friends after classes and on weekends. He plays sport games and likes going to the cinema. He denies having a girlfriend.

Substance abuse: He stated that he did not consume alcohol, medications, or drugs. C.R. denies smoking.

Sex: C.R. denies sexual activity.

Mood: C.R. denies depression or anxiety. He states that he has a good mood.

Concerns: The boy had no concerns or complaints during a visit.

Medical HX (PMH):

Childhood: Term SVD 7 lbs, 9 oz. Brest feeding during first four months, after that – formula feeding. He had regular check-ups and normal developmental milestones.

Adult: N/A.

Surgical: None.

Ob/Gyn: N/A.

Psychiatric: No history of psychiatric conditions.

Immunizations: All needed immunizations:

· HepB: At birth, 1 month, 9 months.

· RV: 1 month, 2 months.

· DTaP: 2 months, 4 months, 6 months, 18 months, 5 years.

· Hib: 2 months, 4 months, 6 months, 15 months.

· PCV13: 2 months, 4 months, 6 months, 15 months.

· IPV: 2 months, 4 months, 1 year

· MMR: 1 year, 5 years.

· VAR: 1 year, 5 years.

· HepA: 12 months.

· MenACWY-D: 12 years.

· Tdap: 12 years.

· Influenza: Annually. Last immunization: 12/2017.

Current Medications: C.R. uses no medications.

Allergies: No allergies are present.

Family History: C.R. lives at home with his parents and older sister. The family has a cat and parrot.

· Cancer? (Y/N); Type/Who/Age if died? No

· Heart Disease? (Y/N); Who/Age if died? Mother’s father died from heart attack at the age of 69.

· Diabetes? (Y/N); Who/Age if died? No.

· Hypertension? (Y/N); Who/Age if died? Mother’s mother has hypertension.

· Stroke? (Y/N); Who/Age if died? No.

· Depression? (Y/N); Who/Age if died? C.R.’s father suffered from depression five years ago. He had a course of cognitive-behavioral therapy and antidepressants treatment. Therapy was successful, and no repeated evidences appeared.

· Alcoholism? (Y/N); Who/Age if died? No.

Social History: Parents are married and have two children. The family lives in a house with a cat and parrot. Family members do not smoke or consume drugs and alcohol. No danger factors affect the patient.

Review of Systems

General: A patient denies excessive weight gain or loss, denies fever, malaise, night sweats, chills, and fatigue, or headache. C.R. states no changes in appetite and denies sleeping problems.

Eyes: C.R. denies vision problems, blurry or double vision, ocular pain, itching, dry eyes, discharge, and denies changes in peripheral vision or focusing. The boy does not use contact lenses or glasses. According to his mother, last vision exam was in 2015, and normal vision was reported.

Ears: C.R. denies ear pain, fullness, popping, vertigo, or discharge, and denies changes in hearing.

Nose: The boy denies nasal bleeding, discharge, allergies, changes in smell, and sinus pressure.

Throat: C.R. denies sore throat or problems with swallowing.

Mouth: The boy denies teeth problems or pain, oral lesions, changes in taste, and gum bleeding. Last dental visit was half years ago, no problems were reported.

Cardiovascular/peripheral vascular: C.R. denies chest pain during rest or exercises, denies palpitation, fatigue, exertion, limbs edema, or SOB. Mother does not report any heart problems, murmur, claudication, or varicose vein.

Pulmonary: The boy denies cough, SOB during rest or exercises, sputum discharge, wheezing, syncope, or snoring. C.R. does not have respiratory infections, hemoptysis, denies exposure to second-hand smoking. Mother denies TB.

GI: C.R. denies abdominal pain, problems with swallowing, nausea or vomiting, diarrhea, pyrosis, reflux, constipation, hemorrhoids, indigestion, or food intolerance. C.R. denies changes in appetite. He eats three-four times a day, mostly healthy home-made food.

GU: The boy denies changes in urination patterns, dysuria, polyuria, blood in urine, nocturia, or weak stream. A patient denies pain during urination. C.R. denies discharge from penis. He denies sexual activity. His mother denies history of stones.

Neuro: C.R. denies headaches, problems with balance, dizziness, tingling limb weakness, paresthesias, tremors, seizures, and changes in activity level. He does not have memory problems or loss.

MS: C.R. denies muscle pain, neck pain or stiffness, back pain, joints pain or swelling, myalgias, limb weakness, cramps, changes in ROM. C.R. is physically active, has swimming lessons twice a week, plays soccer with friends, and walks a lot.

Dermo: The boy denies skin redness, itching, rashes, acne, moles, nails deformation, hives, bruising, skin injuries, or hair loss.

Hematologic/lymph: C.R.’s mother denies blood transfusion or anemia history. C.R. denies unusual bleeding and lymph nodes enlargement.

Endocrine: C.R. denies intolerance to cold or heat, increased sweating, polyphagia, polydipsia, changes in skin, nails, or hair, weight changes, and glove changes. Mother denies any hormonal therapy.

Psych: C.R. denies nightmares, depression, nervousness, anxiety, excessive aggression, or being violent, suicide thoughts or attempts, changes in emotional conditions, memory, sleeping patterns.

Allergies: The boy denies allergies. His mother denies the use of immunosuppressive therapy.

Objective:

Vital Signs: Pulse 92; Temp. 36.6; Resp. 19; B/P 90/60.

Height 62 inches, 56th percentile. Weight 110 lb, 66th percentile.

BMI: 20.1, 71th percentile.

Vision: 20/20 in both eyes.

Review of Systems

General appearance: Well nourished and developed, healthy appearing, 13-year-old male, no signs of acute distress. C.R. appears his stated age.

HEENT: Normocehpalic, has equal pupils, pupils react to the light and accommodation. Extraocular movements are intact. No signs of conjunctivitis are observed. Sclera is white. Conjunctivae are pink. Fundi are benign. Tongue is midline. No lesions are present. Nose appearance is normal. Septum is midline. Nares are patent. Nasal mucous membrane is pink and moist. Ears appearance is normal. Tympanic membranes are pearly gray, no perforation is observed. No redness or swelling is observed. Throat is clean and clear. Pharyngeal membranes are pink and moist. No lesions are observed.

Neck: Supple. ROM is normal. Thyroid size is normal. Lymph nodes are not enlarged. No tenderness is observed.

CV: S1 and S2. Cardiac rate and rhythm are regular. No murmur, rubs, clicks, thrills, or gallops are observed. Normal arm and pedal pulse is observed bilaterally. No bruises are observed. No edema, swelling, cyanosis, or clubbing.

Pulmo: Chest shape and expansion are normal. Asculation sound is clear and equal bilaterally. No wheeze, rales, rhonchi are observed. Lung air movement is normal.

Abdomen: Shape of abdomen is normal. Abdomen is soft, non-distended. No tenderness is observed. Normal bowel sounds are present in all four quadrants. Palpation revealed no masses or organs enlargement. Hernia is absent.

GU: Bladder distention is absent; no pain is present during palpation. Kidney palpation is normal. Penis and testes are normal without lesions. No scrotal mass is observed. No discharge from urethra is observed. No swollen epididymis or scrotal edema. No hernia.

Rectal: Sphincter movement is normal. Results of prostate palpation are normal.

Skin: Skin color is normal. No rashes, lesions, injuries, scars, discolorations, or bruises are observed. Skin tightness is normal. No skin or subcutaneous masses are present.

Hematologic/lymph: No bruises were observed. Lymph nodes are not palpable and have normal size. No tenderness during palpation appeared. No masses were observed.

MS: C.R. has a normal development for his age. Limbs are symmetrical. No tenderness in joints is observed during palpation. The boy has good muscles bulk and tone. All four limbs demonstrated equal strength 5/5. C.R. has intact fine and gross motor. Spine is normal. No lateral curvature is observed.

Neuro: C.R. is alert and well-oriented to person, place, and time. His communication ability is normal. C.R. answers questions clearly and demonstrates appropriate concentration on conversation. RAM are intact. C.R. is capable for point to point movements. C.R. demonstrated straight and stable gait. He was vapable to wal Gait stable and able to walk on heels and toes. Cranial nerves were tested. CN I is not tested. CN II test – visual assessment was performed; C.R. demonstrated 20/20 in both eyes. The boy has positive red-light reflex. CN III, IV and VI – six cardinal gaze fields were tested. Extraocular movement is intact. Eyes movement is bilaterally normal in all six fields of gaze. Pupils are equal, round, and react to the light. CN V is tested. C.R. is capable for teeth clenching. CN VII is tested. C.R. demonstrated an ability to puff his cheeks out. His smile is symmetrical. CN VIII is tested. The boy demonstrated equal well hearing in both ears. CN IX is tested. C/R/ has clear and strong voice. He is capable to cough. CN X is observed. C.R.’s uvula is midline and soft; his palate moves straight up during examination. CN XI is tested. C.R. can lift both shoulders equally against resistance. He is capable to firm jaw pressure against hands. CN XII is tested. C.R.’s tongue is midline. The boy is capable to move it from side to side.

Sensory: C.R. senses are intact. He feels pinprick, light touch to his skin. His position sense is intact. Romberg test is normal; he was capable to keep balance with his eyes closed. No pronator drift was observed.

Psychiatric: Judgments are logical. Rate and order of speech are normal. C.R. is calm, polite, and has a good mood. No anxiety is present.

Impression/Plan

Assessment: Routine Child health examination.

Lab/diagnostic tests/Ekg:

1. Vision and hearing screening.

2. Blood pressure test.

3. CBC (AACC, 2018).

4. Glucose test (AACC, 2018).

5. Lipid profile screening (AACC, 2018).

Immunization:

1. Influenza mist 0.1 nasal (CDC, 2018a).

2. HPV vaccine injection – the first dose (CDC, 2018b).

Plan

Future immunizations plan:

1. Regular influenza immunization every year (CDC, 2018b).

2. MenACWY-D: second dose – 16 years (CDC, 2018b).

3. HPV vaccination – second dose in 12-month after the first dose.

Education:

1. Even though C.R. stated that he was not sexually active, he is an adolescent, and it is important to educate him about sexually transmitted diseases (STD) and importance of condom use. The adolescents get half of new incidences of STDs. Apart from that, they are at the highest risk of getting infected due to the biological and cultural reasons. In particular, the adolescents do not have appropriate knowledge about routs of transmission and danger of STDs. The most prevalent infections are chlamydia, gonorrhea, syphilis, and genital herpes (CDC, 2017). Thus, it is important to educate the boy about main transmission of these illnesses. STDs can be transmitted by unprotected vaginal and anal sex (CDC, 2017). Apart from that, it is important to explain that two most prevalent diseases (chlamydia and gonorrhea) are asymptomatic in most cases (CDC, 2017). Therefore, C.R. should get regular screening for these conditions when he starts to be sexually active. Finally, it is important to educate C.R. about HIV. It is related to education on STDs infection. However, it is important to focus C.R.’s attention on the danger of HIV. It is life-lasting and incurable disease that affects immune system. In this way, it is needed to provide the information about routs of transmission of HIV, including sex without condoms and use of common syringe (HHS, 2018). Therefore, it is important to focus C.R.’s attention on the problem of STDs and HIV as well as methods of diseases prevention.

2. Next, it is needed to underline that vaginal sex without condom might lead to a female pregnancy. Hence, it is needed to use condoms to prevent unplanned child birth.

3. Education about the danger of smoking drugs and alcohol abuse is essential. According to Youth.gov (n.d.), prevalence of alcohol consumption is significant: 27.2% reported consuming alcohol, 18.1% reported binge drinking, and 5.4% reported heavy drinking. Similar rate was estimated for smoking: 27.8% of adolescents try cigarettes, and 11.7% smoked within last month. Finally, 69.9% of adolescents reported that they had tried illicit drugs, including marijuana, stimulants, and opioids (Youth.gov, n.d.). Thus, the prevalence of alcohol, cigarettes, and illicit drugs use among the adolescents is significant. The adolescents start to use cigarettes, alcohol, or drugs due to several factors. Risk factors associated with the substances use are low socio-economic factors, availability of drugs, peers pressure, quality of parenting, and genetical predisposition (Chakravarthy, Shah, & Lotfipour, 2013). Even though C.R. has high socio-economic status, complete family with caring parents, and no substance abuse in family history, he might be influenced by his friends. In this way, appropriate education about the danger and possible health consequences of consumption is needed.

4. C.R. is physically active and has appropriate diet. It is important to encourage him as well as his mother to continue controlling dietary habits and maintaining exercises. No special education for diabetes and overweight/obesity prevention is needed in this case.

Safety Anticipatory Guidance:

1. Establish safety rules: actions in case of emergency: remember to call 911, name the address, and explain the situation briefly and clearly.

2. Follow safety rules on the street: cross street on green light, cycle only at cycle line, and wear bike helmet.

3. Establish communication rules: do not communicate with strangers, sit in unknown car, and remember to call for help in case of emergency.

4. Establish car safety: remember to use seatbelt.

Conclusion

C.R. came for a well-child visit. He is a 13-year-old boy. He came with his mother. He seems to have good physical and mental health. C.R. is physically active and has an appropriate diet. He reported no health problems. C.R. has all needed immunizations for his age. Physical examination did not reveal any health issues. Health education should be focused on the importance of condom use for the prevention of STDs and undesired pregnancy of possible female partners. It is important to discuss the danger of possible alcohol, tobacco, and illicit drug use. Finally, anticipatory guidance was established.