Description
do this one in the same way as the example. This patient is female need a growth cart with this as well tanner staging 1 breast budding. This child is here for well check up no problem only child Immunization must be listed all are up to date for her
Explanation & Answer
Thank you for working with me.
Running Head: 9 YEAR WELL GIRL
1
9 Year Well Girl
Name:
Institutional affiliation
9 YEAR WELL GIRL
2
SOAP NOTE
Name W. D.
Date: 11th Sep 2017
Time: 08:00AM
DOB: 21st Sep 2008
Age: 9 YEARS
Sex: FEMALE
Place of Birth: San DiegoCalifornia
SUBJECTIVE
Historian: The mother of the child
CC: “ my baby is here for the annual check-up.”
HPI:
W.D. is a nine-year-old Hispanic girl who according to her mother, her social conduct as
well. The mother elaborates that though W.D. needs some assistance in doing some
activities, the child is able to do the majority of the chores on her own. W.D. diet is
healthy having fruits, vegetables, cereals, iron rich foods and eggs according to the report
given by her mother. The mother also adds that the girl has a good appetite, but has
reported that W.D is allergic to pet fur. Further reports indicate that there is a regular
bowel movement of the child. The child sleeps approximately at 7 PM and wakes up at 6
AM which indicate good sleeping habits. Reports indicate adequate urine output. W.D.
has transformed well moving from third grade to the current fourth grade. The mother
reports that the child is active in school activities like sports and she has a good
relationship with the teachers and her schoolmates. The mother has come with safety
9 YEAR WELL GIRL
measures for the patient including avoiding keeping pets her home. Keen focus on water
safety, protection from hot surfaces, and ensuring that W.D. safety helmet while riding
bicycle with her friends at the neighborhood during weekends and holidays
PMH
Allergies:
The mother reports that the child is allergic to pet fur
Medication
For nutritional benefit, the child can take daily Multi-vitamin PO
Medication Intolerances:
The patient has no any medical intolerance
Chronic Illnesses/Major traumas
There are no any major chronic illnesses or major traumas that have been reported to the
client
Hospitalizations/Surgeries
No hospitalizations to date
3
9 YEAR WELL GIRL
Immunizations
Hepatitis B (HepB) vaccine 11th Sep 2017 (third dose)
Hepatitis A (HepA) vaccine: 11th Sep 2017 ( second dose)
Influenza vaccines :11th Sep 2017 (first dose)
( CDC, 2017)
Family History
W.D. Mother reports that she does not have any chronic illness. The grandparents of the
patient are not alive. The grandfather from the dad’s side succumbed due to prostate
cancer, ...