E.M. is an 18 month old healthy appearing Caucasian female who presented to the clinic for a

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1 Kallendrf-SOAP #1 nte S: (Subjective data) E.M. Pt number mnth 15 days ld Caucasian female Infrmant B.M.-mther L.M.- father CC We brught her in fr a rutine checkup -B.M. HPI E.M. is an 18 mnth ld healthy appearing Caucasian female wh presented t the clinic fr a rutine 18 mnth well-child visit. She lives with bth parents and bth are present fr this appintment. She has ne lder sibling wh is als in daycare. Her parents are attentive t her during this visit and bth are answering questins abut her develpmental milestnes. Mm reprts that she eats very well and denies her being a picky eater. She reprts that E.M. drinks 8-16 z. f whle milk a day frm a cup and feeds herself a variety f table fds withut issue. E.M. is reprted by her parents t sleep thrugh the night in her wn bed. She ges t bed at apprximately 1930 each night. She des nt use a bttle, sippy cup, r pacifier at bedtime. Her father reprts that she des nt use a pacifier in general. He als reprts that she gets her teeth brushed twice daily. Mm reprts that she interacts as she expects her t with new situatins and with her peers in daycare. Mm denies that the daycare prvider has reprted any cncerns. Bth parents deny any cncerns at this checkup and bth parents agree she is n track since her last well child visit at 15 mnths f age.

2 Kallendrf-SOAP #1 nte PMH E.M. has had n majr illness t date. She has n histry f majr prblems. Her histry des include: Immunizatins up t date fr age UTD n the fllwing: Hep B Rtavirus DTap- fifth dse at 4-6 y/ Hib PCV 13 IPV- furth dse at 4-6 y/ MMR- secnd dse at 4-6 y/ Varicella- secnd dse at 4-6 y/ Due fr her secnd Hep A vaccine tday Parents due elect t get influenza vaccine annually. Will be called when flu clinic is initiated Seasnal allergies Treated with Zyrtec Children s Allergy 1mg/ml 5 ml daily Screenings Autism Spectrum Disrder MCHAT Develpmental Surveillance PSH Nne

3 Kallendrf-SOAP #1 nte Current Medicatins Zyrtec Children s Allergy 1mg/ml 5 ml daily Allergies NKDA Seasnal allergies, n specific allergy tested has been cmpleted FH Mther living at 33. Alive and well Father living at 34. Alive and well Maternal grandparents bth alive and well. Maternal grandfather with hyperchlesterlemia Paternal grandparents bth alive and well. Paternal grandfather with arthritis and hypertensin. Maternal grandmther with hypertensin. SH Parents deny tbacc use, alchl intake, r illegal drug use. Patient ges t daycare Mnday thrugh Friday Sits in 5 pint harness car seat with latch system Lives with bth parents and her lder sister Drinks city water Uses Blue Crss Blue Shield fr insurance with prescriptin drug cverage. Strng supprt system with clse immediate and extended family. ROS General appearance: this is a well-develped, well nurished, Caucasian female wh appears t be in n distress. Skin: negative fr rash, lesin, itching, hives, edema, abnrmal skin clr, r dryness.

4 Kallendrf-SOAP #1 nte Head: unremarkable is nrmcephalic, with n bruising nted. Eyes: negative fr itching, redness, swelling, discharge, pht phbia, visual lss. Ears: negative fr ear pressure, pain, discharge, hearing lss. Nse: negative fr nasal discharge, nasal cngestin, sinus pain, nse bleed, sneezing, pst nasal drip. Muth and thrat: negative fr difficulty swallwing, harseness, muth ulcers. Neck: negative fr enlarged lymph ndes, pain, stiff neck, swelling. Respiratry: negative fr cugh, wheezing, dyspnea, tachypnea. Cardivascular/Peripheral Vascular: negative fr cyansis, swelling, erythema f skin. Gastrintestinal: Negative fr abdminal pain, nausea, vmiting, cnstipatin, diarrhea Urinary: Negative fr bld and urine, vaginal discharge Musculskeletal: negative fr weakness. Psychiatric: Negative fr agitatin, anxiety. Neurlgical: negative fr weakness, lss f cnsciusness, unsteady gait, paralysis, and tremr. Hematlgic: Negative fr easy bruising r bleeding. Endcrine: Negative fr heat r cld intlerance, excessive sweating, excessive thirst r hunger, plyuria. O: Objective General Appearance: this is a well-develped, well nurished, Caucasian female wh is currently appears t be in distress. Vital Signs: temp 97.9, respiratins 26, bld pressure 96/62, heart rate 120 Ht 32.8 inches Wt 26 lbs

5 Kallendrf-SOAP #1 nte BMI 17.3 Full Physical Exam Head: unremarkable, nrmcephalic, with n bruising nted. Eyes: Pupils are equal rund and reactive t light. Sclera white, extra cular mvements intact. N hemrrhage r exudate nted. Ears: clear external auditry canals, pinnae nrmal shape, n pre-auricular pits r skin tags. TM s visualized, pink-grey bilaterally with n bulging nted. N erythema r discharge. Nse: nares patent bilaterally, septum midline, nrmal pink mucsa, n plyps, n discharge Muth/Thrat: 10 teeth w/ -caries, tnsil withut exudate, buccal mucsa mist, psitive gag reflex. Orpharynx w/ n signs f erythema r ulceratin. Nrmal mvement f sft palate. Neck: Supple with n lymphadenpathy. Trachea midline with full ROM. N JVD is appreciated. CV: regularly irregular rate and rhythm, S1 and S2 were heard with n rubs, murmurs, r gallps. N S3 r S4 nted. Pulmnary: Lungs clear t auscultatin bilaterally. Patient is breathing cmfrtably n rm air. Gastrintestinal: abdmen sft, nn-tender, nn-distended, bwel sunds are present in all fur quadrants. N rganmegaly is palpated. Extremities: n clubbing r cyansis and nted. Bilateral lwer extremities with n edema. Plus tw pedal pulses nted bilaterally. Calves supple nne tender. Neurlgic: patient in awake and alert with n fcal deficit. Mves all extremities symmetrically with apprpriate tne; DTRs with negative tremr/clnus; psitive sensatin.

6 Kallendrf-SOAP #1 nte Psychiatric: Md and affect apprpriate. Well-adjusted and cmfrtable during exam. Skin: warm, dry, intact. N rashes, lesins, r unusual bruising. Musculskeletal: Symmetrical with full ROM. Negative kyphsis, lrdsis, jint swelling Mtr: gd muscle tne. Apprpriate fine and grss mtr skills. A: Assessment Diagnsis: Well Child Exam ICD9= V20.0 Prcedure: OV PS Est Pt Age 1-4: Prblem list N active majr medical prblems Chrnic health prblems Seasnal allergies well cntrlled Health Maintenance Safety Car safety Water safety Wearing a helmet Creating a safe envirnment t explre at hme Leaving medicatins and cleaners ut f reach Behavir and cnsistency Discipline Time-uts Develpment Reading with child

7 Kallendrf-SOAP #1 nte Nutritin and ral health Aviding sugary drinks and encuraging water intake Using whle milk until 2 years f age Brushing teeth twice a day Healthy sleep habits Tilet training tips P: Plan This is a pleasant 18 mnth ld female patient sitting in her mther s lap. She is develpmentally apprpriate fr her age. She will receive her Hep A vaccine tday. Her parents have cmpleted the MCHAT fr Autism screening and she passed this screen withut cncern. I have discussed health maintenance with the parents as listed abve. Discussed anticipatry guidance fr the next 6 mnths until 2 year visit. I have addressed and answered all parental questins regarding develpment. The parents have been given an educatinal handut fr vaccine and expected 18 mnth develpment. Fllw up visit t be scheduled fr 2 year checkup and parents advised t return fr annual influenza vaccine. Parents have verbalized understanding.

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