SOAP Note: Proper Child Examination

Child Profile: The mother says that she sleeps throughout the night. She goes to bed at around eight hours each day. The mother says that C.P. does not rely on a sippy cup, pacifier, or bottle during bedtime. Moreover, C.P has her teeth brushed two times daily. The mother reports that C.P. interacts freely with peers in the daycare. The mother denies her caregiver ever reporting any fears. She says that she is not concerned during this check-up; instead, she acknowledges that C.P. is progressing well since her last visit when she was 15 months old.

HPI: C.P. is 18 month, 17 days old Caucasian female. The healthy-appearing child has been brought to the clinic by her mother for her regular well-child visit. The client lives with both of her parents. She has another sibling, who is in grade one. The mother is attentive during the visit and appropriately answers questions regarding her developmental signs of progress. The woman says that the child eats well and denies C.P. being picky with the foods that she eats. The mother says also that the client drinks between 8 and 14 oz. of whole milk daily from her cup. She says that C.P. eats various table foods without any issues.

Treated with Zyrtec 1mg/ml at 5ml per day for seasonal allergy.

C.P. does not have major illnesses so far. Her history includes immunizations that are up-to-date and appropriate for her age. She is up-to-date on Hepatitis B, Rotavirus, DTap, Hib, PCV, and IPV. Other immunizations that she has received are MMR and varicella. She is supposed to receive her second dose of Hepatitis Virus A vaccine today. Besides, the mother has chosen that she receives influenza vaccine every year. However, she will be invited to the clinic when the flu vaccine is commenced. She has seasonal allergies for which she is receiving Zyrtec medicine. C.P. has been screened for autism spectrum disorder (ASD) using MCHAT with her development surveillance being in order.

Allergies: NKDA. There has never been specific allergy test conducted for her seasonal allergies.

Medication Intolerances: No known history.

Chronic Illnesses/Major Traumas: No known history.

Hospitalizations/Surgeries: No known history.

Her mother is 35. She is well. The father is 34. He is well. The client’s maternal grandparents are all alive and living well. However, the maternal grandfather suffers from hypercholesterolemia. Similarly, the paternal grandparents are alive and are well. The paternal grandfather has arthritis as well as hypertension.

Social History

The mother denies both of the client’s parents using tobacco, taking alcohol, or consuming illegal drugs. The client is taken to a daycare, five days a week from Monday to Friday. The mother says that C.P. sits in a 5-point harness seat reserved for her in the family car that has a latch system. The client lives together with both of her parents as well as with an elder sister. The client drinks water provided by the city. She has a health insurance that covers prescription drugs. The child has a strong support system from her immediate family as well as extended family.

The client is a well-developed and well-built Caucasian female. She does not seem to be in any kind of distress.

She does not have skin erythema, cyanosis, or swelling.

She does not have lesions, rashes, itching edema, any kind of abnormal color and dryness.

She does not have wheezing, tachypnea, cough, or dyspnea.

She does not have itching, loss of vision, photophobia, redness, discharge, or swelling.

She does not have abdominal pain, vomiting, diarrhea, constipation, or nausea.

She does not have ear pain, loss of hearing, discharge, or pressure in ears.

She does not have vaginal discharge, blood or urine.

She does not have discharge from the nose, congestion of the nose, sinus pain, sneezing, nose bleeds, or postnasal drips. Negative for swallowing difficulties, mouth ulcers, or throat hoarseness. She is negative for lymph nodes enlargement, neck pain, swelling of neck, or stiff neck.

She denies weaknesses.

The girl does not have lumps, bumps, or any changes.

She denies weakness, unsteady gait, unconsciousness, paralysis, or tremor.

She does not have bruising or bleeding. Also, the client is negative for heat and cold intolerance, increased sweating, increased thirst or hunger, or even polyuria.

The girl does not have anxiety or agitation.

The healthy appearing child is not in any form of distress. She is alert as well as oriented.

The skin is warm, dry and intact. There are no rashes, unique bruising or lesions.

Unremarkable and normocephalic without bruising. Her eyes pupils are equal, round, as well as reactive to light. The sclera is white with extra ocular movements that are intact. There is no hemorrhage or exudates. External auditory canals are clear, while pinnae have a normal shape; there are no skin tags or pre-auricular pits. Tympanic membrane is visualized as pink-grey bilaterally without any kind of bulging. There is no ear discharge or erythema. The nose has nares with bilareal patent, while septum is midline. The nasal mucosa is pink, no polyps or discharge noted. Ten teeth without dental caries tonsils that do not have exudates. Her buccal mucosa is moist, and she is positive for gag reflex. Her oropharynx is without any sign of ulceration or erythema, while the soft palate has normal movement. Her neck is supple without lymphadenopathy, while the trachea is midline and has full range of motion. There is no JVD noted.

Heart beat is regularly irregular with S1 and S2 heard. There were no murmurs, rubs, or gallop. There was no S3 or S4 noted.

Lungs were clear to auscultation bilaterally. The breathing was non-labored in the examination room.

Abdomen is soft and non-tender, without distention. Bowel sounds heard in all of the client’s quadrants. No palpitation of organomegaly.

Breasts without masses, tenderness, discharge, dimpling, or wrinkling. There is no skin discoloration

Normal bowel sounds, abdomen is non-distended, without hepatosplenomegaly or even masses.

Symmetrical with full range of motion. She does not have lordosis, kyphosis, or swelling of the joint. Full range of motion in all of the four quadrants, as she moved in the examination room. No cyanosis, while bilateral lower extremities without edema. Calves were supple and non-tender. Muscles with good tone and appropriate motor skills.

She is awake, alert without focal deficit. She was able to move in all the extremities symmetrically. She is positive for sensation.

Her mood was appropriate. She was also well-adjusted as well as comfortable when the examinations were being conducted.

The Pediatric Assessment Triangle (PAT) was used. The tool determines the clinical status of a child as well as the category of illness so that initial management is directed (Horeczko, Enriquez, McGrath, Gausche, & Lewis, 2013). In this assessment, the client had a likelihood ratio (LR) of 2.2, meaning she does not have respiratory distress, LR of 3.2, meaning she does not have respiratory failure, 3.1, meaning she is not at risk for shock, 4, meaning she is not at risk for metabolic disorder, and 24, meaning she is not at risk for cardiopulmonary failure. Similarly, the resilience questionnaire was used in the assessment. The tool is used to assess the resilience of parents as well as support system (American Academy of Pediatrics, 2018). The parent for the client showed great resilience and support system that was accorded to her by the parents given the answers that she provided during the questioning. Finally, M-CHAT was used to assess the patient. The tool with its 7-questions assesses a toddler for risk of autism (Toh, Tan, Lau, & Kiyu, 2018; Cuesta-Gomez, Manzone, & Posada-De-La-Paz, 2014). The client was not found to be at risk for autism given the result of the assessment.

There were no special tests performed during the visit.

Proper child examination.

No active serious medical issues.

Seasonal allergies that are well controlled.

· Plan:

· No test to be conducted.

· Safety for the client should focus on car safety, water safety, as well as wearing helmet when appropriate. There would also be the need to create for her an environment that would encourage exploring. Medications as well as cleaners would be left beyond her reach.

· Behavior as well as consistency would be vital. She would be taught about being disciplined, especially whenever she needs time-out.

· Development plan would involve reading with her.

· Other education tips would focus on nutrition as well as oral health where she would need to avoid sugary foods, encourage her to drink a lot of water, continue with milk until she turns 2 years old, and brushing her teeth. Apart from that, healthy sleep patterns and good toilet training are important plans to incorporate.

· The patient will receive her Hepatitis A vaccine today. The parent has also completed the MCHAT, PAT, and resilience questionnaire, which she passed without concern. The result of the MCHAT indicates that the child does not have concerns about autism. Follow-up will be done after two years, but the parents have been advised to come for annual flu vaccination.