KING UNIVERSITY MSN/NP PROGRAM

CLINICAL SOAP NOTE FORMAT

PEDIATRICS
Student: Susan Kelly Course: 5024

SOAP Note: #1 Well Visit Date: 5/4/2018

Patient Information:

Initials: C. G. Age:15 Gender: M DOB:12/29/2002

Medical/ surgical history: Recent in-patient stay at The Village Behavioral Health Facility for

depression. No surgical history.

Birth History: Step-mother reported mother had a vaginal delivery at forty weeks to her

understanding with no reported complications. OB/GYN appointments followed as physician

requested. Step-mother is unsure if mother took prenatal vitamins. C. G. was bottle fed for the

first full year, step-mother is unsure of which formula was used. Birth weight was eight pounds

two ounces. Step-mother is unsure about group B strep. No reports of gestational diabetes

mellitus, hypertension, or pre-eclampsia. Step-mother reports mother did not use tobacco or

alcohol during pregnancy nor was it allowed in the home after birth. Step-mother reports the

home is alcohol and tobacco free. APGAR score is unknown. Step-mother reports mother was a

G1 P1 A0. C. G. was diagnosed with depression a “few months ago.” Step-mother states all

vaccines are up to date, flu vaccine was given in November 2017.

Family/Social: C. G. was recently expelled from the public-school system for presenting to

school with a weapon. Currently, C. G. is being home schooled. Step-mother reports a recent

change in social interaction. Step-mother reports C. G. will be calm and attentive then

“immediately starts pacing and rubbing his head.” C. G. does attend Sunday School. However,

he does not actively participate.

 C. G.’s step-mother reports that his mother and father divorced when C. G. was five she

met and later married C. G.’s father when he was seven. C. G.’s father has full custody. C. G.’s

step-mother reports they live in a single family one level ranch style home that was built in 2000,

and the home was built energy efficient. C. G.’s step-mother feels the home is located in a

“good” area of Hamblen County and feels as if it is a safe place to raise C. G. C. G. does not

have a brother or sister. C. G. had one pet (a cat) that died three months ago of natural causes.

This was a traumatic event for C. G. as he was the one who found the cat, the cat was C. G.’s

“best friend.” C.G.’s step-mother reports both maternal and paternal grandparents live close they

are without medical disparities and have an active part in C. G.’s life. C. G. does have a

biological uncle that lives in another state which he sees annually. C. G. has a step-aunt and

uncle that are an active part of his life.

Immunization status: Up to date

Meds/Allergies: NKA and no current medications

Chronic Illnesses: Depression

Accompanying adult: Step-mother who serves as a primary care provider for C. G. she is not

employed and is a “stay at home mom.”

Medical equipment: No medical equipment currently in use

(S)ubjective Data
CC: Well Visit

HPI: Presented for Well Visit

Onset Not pertinent

Location Not pertinent

Duration Not pertinent

Character Not pertinent

Associated factors Not pertinent

Relieving actions: Not pertinent

Severity: Not pertinent

Pattern: Not pertinent

Date of last WCC: December 18, 2017

Facility where immunizations are given: Tennova Primary Care

Problems associated with previous immunizations: No problems noted

Nutritional Assessment: C. G. eats three meals a day along with two to three snacks. C. G.’s

step-mother reports he is a very healthy eater. Breakfast consists of free range eggs; two

scrambled with two pieces of whole wheat toast and some type of berry jelly with orange or

apple juice and milk. Mid-morning snack is some type of fresh fruit. Lunch is a protein and two

vegetables such as a grilled chicken breast, green beans and a baked potato or an oven roasted

turkey sandwich with cheese, lettuce, tomato and mayonnaise with baked plain chips and 100%

fruit juice. Afternoon snack is typically cheese or peanut butter and crackers. Dinner is a protein,

starch and a green vegetable or salad with juice or milk. C. G. has a snack before bed which

consists of a bowl of cereal, Cheerios or Corn Flakes, or string cheese, fresh fruit or yogurt and a

glass of milk.

Elimination patterns: C. G. reports daily bowel movements later in the evenings, reports stool

is “usually” brown, formed and “looks like snakes.”

Sleep hygiene & patterns: Step-mother and patient reports difficulty sleeping “rambles” during

the night sleeps in approximately four-hour intervals. C. G. takes daily showers and brushes his

teeth two times a day.

Behavioral concerns: Step-mother reports C. G. has been an in-patient at The Village and is

very concerned with the patient’s behavior and aggression toward her. C. G. expresses a fear of

“doing the job” if he had “something sharp.” When ask to elaborate C.G. stated he was afraid he

would kill himself.

Developmental assessment: See Erickson’s stage of development. Reports no interest in

romantic relationships, expresses frustration with parents when they disagree with C. G.’s

thoughts and wishes. Reports no close friends identifies his cat was his best friend.

Hearing assessment: Whisper test preformed, no issues identified.

Vision screen: Snellen chart 20/20 bilateral

Dental visit/vision test: Step-mother reports both dental and vision tests are up-date she reports

C. G. sees a dentist and ophthalmologist annually.

Social interaction: Home, school, family C. G. is currently home schooled and has no close

friends. C. G. interacts mostly with his parents and step-mother. Step-mom reports minimal

interaction at times and contributed that to his age.

Review of Systems:

Sleep: Step-mother and patient reports difficulty sleeping “rambles” during the night sleeps in

approximately four-hour intervals.

Diet: Regular diet no issues or concerns reported. Step-mother reports overall healthy diet with

minimal intake of sugary drinks. See Nutritional Assessment.

Elimination: No reports of diarrhea or constipation, no reports of excessive flatulence or flatus.

No reports of bloody or mucoid stools.

Behavior / activity: Step-mother reports isolated behavior with lack of desire to befriend others.

C. G. does not actively participate in sports or other age-related activities.

Head: No reports of oily, dry or itchy scalp. No reports of abnormal hair growth or loss. No

reports of infestations, headaches, dizziness, syncope, or loss of consciousness.

Eyes: No reports of blurry or double vision, no reports of sensitivity to light, floaters, itchy,

watery or red eyes.

Ears: No reports of loss of or decreased hearing. No reports of drainage, tinnitus or vertigo.

Nose: No reports of congestion, sneezing, rhinorrhea, or epistaxis. No reports of sinus pain or

pressure.

Throat: No reports of changes in voice, sore throat, dysphagia, loss of teeth or change in taste.

Skin: No reports of itching, rash, bruising, cuts or scratches.

Respiratory: No reports of shortness of breath at rest or with activity. No reports of cough,

sneezing, congestion, or wheezing.

Cardio: Denies chest pain, tightness, burning or funny feeling.

GI: No reports of dysphagia, nausea, vomiting, diarrhea, cramping, daily BM without difficulty.

No reports of reflux, heartburn, loss or decrease of appetite. No reports of abdominal pain.

GU: No reports of frequency, urgency, hesitancy, incontinence, dysuria, hematuria, or nocturia.

Endocrine: No reports of heat or cold intolerance, goiter, polyphagia, polydipsia, dry hair or

skin.

MS: Denies joint stiffness, muscle cramps, or swelling. No reports of difficulty with ROM or

ambulation.

Neuro: No reports of headache, seizures, loss of vision, hearing, speech, syncope or vertigo.

Psych: Developmental assessment of milestones (per parent): No reports of developmental

delays per step-mother. Reported new diagnosis of depression.

Objective Data:
Vital signs:
T: 97.6 P: 72 R: 16 BP: 133/66 HT: 6’1” WT: 175 BMI: 23.1 Pain:0/10
Percentile on growth chart: WT: 86.4 HT: 95.3 HC: Not Pertinent
Erickson’s Developmental Stage: Identity – VS- Role Confusion

During adolescence, young people are expected to develop their sexual identity. This is gained

through the discovery of oneself and in the course of finding meaning to their personhood. They

may also experience identity crisis as a result of the transition from childhood to adulthood.

Some adolescents may feel confused and are unsure whether an activity is age-appropriate for

them. Crisis at this stage may also be brought about by expectations from themselves and from

people around them, e.g., their parents.

This stage of Erickson’s theory has not been met at this point as C. G. does not express a sense of

self. C. G.’s social interactions and social skills are impaired at this point in his life. He was

expelled from public school for bringing a weapon and does not have friends; his cat was his

“best friend.” C. G.’s step-mother denies awareness of the apparent issues with C. G. until this

office visit. C. G. is very insecure and unsure of where he fit’s in in today’s society.

Appropriate or delayed

LAB Data: Deferred until next visit

Constitutional: Pleasant, well mannered, well groomed, well nourished, Caucasian male sitting

erect in a chair. Dressed appropriate for age and weather. Cooperative made minimal eye contact

and interacted appropriately during physical exam. No guarding fidgeting or grimacing noted.
Actively participated in answering questions at the beginning C. G.’s demeanor changed when

questioned about his social interaction. C. G. expressed the desire to do self-harm if given the

opportunity.

Head: Normocephalic, no infestations, flakes, abrasions, or raised areas on scalp, eyebrows,

crust noted on eyelashes.

Eyes: PERRLA 2 and brisk red reflex. Sclera white, pale yellow crust and periorbital erythema

noted.

Ears: Bilateral tympanic membranes visualized, pearly grey no redness or bulging noted.

Bilaterally equal to the lateral aspect of the eyes.

Nose: Nares patent bilateral without septal deviation. No polyps or bogginess. Frontal, maxillary,

ethmoid, and sphenoid sinuses without tenderness. Clear secretion bilateral nares.

Throat: Tonsils 2+ tonsils and pharynx no erythema or exudate, no lymphadenopathy noted.

Buccal mucosa, tongue, and gums pink and moist. Hard and soft palate without deformity.

Lymph: Preauricular, postauricular, parotid, occipital, tonsillar, submandibular, anterior

cervical, posterior cervical, submental, and supraclavicular without enlargement.

Skin: Pink, warm, dry, intact without rash, ecchymosis or edema. Old scaring noted to left upper

and lower extremities suggestive of cutting.

Respiratory: Respiratory rate even and unlabored resonant throughout no wheezing, crackles,

or rhonchi noted. Lung expansion is symmetrical.

Cardio: RRR, S1 S2 no murmur noted. Radial and pedal pulses 5/5.

Abdomen: Non-tender, non-distended without herniation. Normoactive bowel sounds x4

quadrants. No abdominal bruit noted. No reports of pain or tenderness with light and deep

palpation. No hepatosplenomegaly. No reports of CVA tenderness.

Genitalia (with Tanner staging): Refused examination

MS: Full ROM to all joints no swelling or redness. Cervical spine with full extension, flexion,

and rotation. Thoracic, lumbar spine full ROM forward bend and toe touch without difficulty. No

scoliosis or kyphosis noted.

Neuro: Alert, oriented times four. Cranial nerves are intact. Limbs symmetrical without gait

disturbance. No balance or coordination disturbance.

Psych/behavior:

Other: C. G. presented in a clam, cooperative manner no issues identified during physical exam,

while questioning C. G. his demeanor changed he became anxious and stated pacing. C. G.

expressed the desire to do self-harm if given the opportunity. After a telephone interview with

Mobil Crisis, C. G. eloped and had to be detained by a local police officer.

(Assessment) Dx:

Suicidal Ideation R45.851

Rhinorrhea J34.89

Differential Diagnoses: (this includes any diagnoses which could be considered using the
above information)

1. Bipolar F31.3

2. Anxiety/Depressive Disorder F41.2

3. Schizophrenia F20.9

(Plan)

Immunizations needed: No immunizations this visit.

Non-pharmacologic Symptomatic Care for an illness or problem: Consult to Mobil Crisis

Pharmacologic Care:

Medications: No medications were prescribed during this visit.

Follow-up instructions: Patient will follow-up as needed after in-patient treatment.

Other: Due to the expression of suicidal ideation Mobil Crisis was consulted, and the patient

was transported to an in-patient facility where he will await placement at a psychiatric facility.

Education / Preventive care / Sick or well visit Age Appropriate Education/Anticipatory

Guidance (parent and/or patient):

 Well child visits yearly

 Always wear a safety helmet with elbow and knee pads when riding a bicycle, roller-

skating, or skateboarding.

 Always wear a seatbelt when ridding in a motor vehicle.

 Family fire escape plan was reviewed.

 Never talk to or take items from strangers; stranger danger discussed.

 Reviewed the need for daily exercise and limit time spend in front of the television and

playing video games to two hours a day.

 Daily bathing or showers with brushing teeth twice a day and flossing at least once a day.

 Discussed firearm safety with step-mother, instructed her to keep all firearms and any

item that may be used as a weapon in a secured locked location.

 Avoidance of soft drinks and increasing water intake. Eat 1200 kcal/day, at least two cups

of milk a day, three ounces of lean meat/day, one and a half cups of fruit/day, one cup of

vegetables/day, four ounces of grain/day.

  Reviewed next steps for vaccines sixteen to eighteen years: Meningococcal, Influenza,

and pneumonia vaccines were also discussed.

 Discussed with C. G. the importance of keeping “private parts” private and to

immediately tell her parents if anyone attempts to touch him inappropriately. We

discussed the fact there was no secrets between him, his parents and his provider. We

also talked about his home and the doctor office being “safe zones.”

 Discussed with step-mom the importance of expressing interest in C. G.’s extracurricular

interests and activities.

 Discussed the importance of parental support and encouragement to become involved in

activities such as sports and complementing accomplishments.

 Discussed the importance of spending time with C. G. doing thing he has interest in and

allowing him the opportunity to express himself as well as respecting his privacy.

 Discussed the importance of avoiding substance abuse and avoiding individuals that

participate in substance abuse.

 Discussed the importance of rules and respect for both the parents and C. G.

 Discussed proper technique and time frames to brush teeth, floss and use mouthwash to

prevent dental caries. Along, with the avoidance of sugary drinks, candy, and foods.

COMPETENCIES

3 NONPF Competencies:

1. Scientific Foundation Competency

Critically analyzes data and evidence for improving advanced nursing practice.
Integrates knowledge from the humanities and sciences within the context of nursing services

Translates research and other forms of knowledge to improve practice processes and outcomes

This competency was met due the advanced knowledge learned through King University’s

Family Nurse Practitioner program signs and symptoms were taken into consideration along with

a detailed history and physical to reach a conclusive diagnosis. This patient may not have

received appropriate care without this visit.

2.Quality Competency

Uses best available evidence to improve quality of clinical practice continuously

Evaluates the relationships among access, cost, quality, and safety and their influence on health

care.

Evidence based practice was utilized in the treatment plan for this particular patient as well

utilizing extended services available to meet the immediate needs of both the patient and

healthcare facility.

3.Independent Practice Competency

Practices independently managing previously diagnosed and undiagnosed patients.

Provides the full spectrum of health care services to include health promotion, disease

prevention, health protection, anticipatory guidance, counseling, disease management, palliative,

and end of life care.

Uses advanced health assessment skills to differentiate between normal, variations of normal and

abnormal findings.

Advanced assessment skills were utilized to diagnosis, treat and educate the step-mother as to the

current state of her step-son. Through advanced knowledge and assessment skills, this patient

will receive advanced treatment.

References

Clinical Growth Charts. (2010) (p. 6). Retrieved from

https://www.cdc.gov/growthcharts/data/set2clinical/set2color.pdf

Dietary Recommendations for Healthy Children. (2014). Heart.org. Retrieved from

http://www.heart.org/HEARTORG/HealthyLiving/Dietary-Recommendations-for-

Healthy-Children_UCM_303886_Article.jsp#.WmJ-AzdG3IU

Epocrates Online. (2018) Online.epocrates.com. Retrieved from https://online.epocrates.com

Preventive Care Children. (2018). HealthCare.gov. Retrieved from

https://www.healthcare.gov/preventive-care-children/