NP Student Name: Kayla Stevens Child’s Initials: LS DOB: 06/12/2016
Clinical Date: 07/02/2019 Age: 3 Place of Born: Douglas, GA
Week Soap Project: W10 Sex:
M __X_
F ___ Type of Soap Note:
Well child visit ____
S
...
NP Student Name: Kayla Stevens Child’s Initials: LS DOB: 06/12/2016
Clinical Date: 07/02/2019 Age: 3 Place of Born: Douglas, GA
Week Soap Project: W10 Sex:
M __X_
F ___ Type of Soap Note:
Well child visit ____
Sick visit __X__
SUBJECTIVE
Historian: Parent
Present Concerns/CC: "I think he has tonsillitis again"
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): The toddler is toilet trained but does continue to wear pull ups as he does still have “accidents”. The toddler feed himself with a spoon and fork. The toddler can drink from a cup. The toddler brushes teeth with help. The toddler does require help dressing.
Safety Practices: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seat, mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
Nutrition: Mother states that the child drinks 2% milk approximately 2 cups per day. States that the child drinks juice and soda occasionally. States the child is a picky eater and is currently only wanting to eat “mac and cheese” but she does try to ensure that he has vegetables and well balanced meals.
Changes in daycare/school/after-school care: No changes. Attends day care while mother and father work during the day.
Sleep: The toddler sleeps with mother and father in their bed. The toddler usually goes to sleep around 9pm and wakes up at 8 am. Mother reports toddler sleeps through the night. Does take one nap per day.
Sports/physical activity: NA
Developmental History:
- Gross motor: Walks up/down steps, able to kick a ball with direction, jumps with both feet, can catch a ball, rides a tricycle, dresses with assistance
- Fine motor: Scribbles on paper, colors pages, can build a tower of 9-10 cubes, puts on shoes, uses scissors, copies circle
- Cognitive: Follows simple commands, names items in pictures, knows colors, knows shapes, can count to 10.
- Social/Emotional: plays well alongside other children, does occasionally have a difficult time sharing toys, enjoys pretend play such as pretending to be a policeman or cowboy
- Communication: Speaks in 3-4 word sentences.
Sexual History (if appropriate):NA
HPI:
The patient is a 3-year-old white male who presents with his mother secondary to fever and vomiting X 2 days. States she thinks tonsils are swollen and this gagged him and caused vomiting. Mother states they have been rotating Tylenol and ibuprofen at home for fever. States she fears it is tonsillitis again, states this is the 3rd time the child has had it this year. Denies any further complaints at present.
Medications:
No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for his fever.
PMH:
Allergies: NKDA
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries: None reported
Immunizations: Up-to-date
Family Medical History (Identify all immediate family members, their age, & health status)
Mother: 39-year-old white female with diabetes; II.
Father: 42-year-old white male with high hypertension
Older sibling (10 year old male)- no known health problems
Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Current living situation/p-artner/marital status: Lives at home with mother, father, and older sibling.
Educational level (as appropriate): NA
Occupational history (as appropriate): NA
Substance use/abuse (ETOH, tobacco, and marijuana): NA
Firearms in home: Father has guns which mother states are stored in a locked safe
Safety status: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seatmother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
References
Abraham, Z. S., Bazilio, J., Kahinga, A. A., Manyahi, J., Ntunaguzi, D., & Massawe, E. R. (2019). Prevalence and Bacteriology of Tonsillitis among Patients attending Otorhinolaryngology Department at Muhimbili National Hospital, Dar es Salaam-Tanzania. Medical Journal of Zambia, 46(1), 33–40. Retrieved from https://search-ebscohost-com.southuniversity.libproxy.edmc.edu/login.aspx?direct=true&db=a9h&AN=136722292&site=eds-live
American Association of Pediatrics (AAP). (2017). Bright futures tool and resource kit. Retrieved from https://brightfutures.aap.org/materials-and-tools/tool-and-resource- kit/Pages/default.aspx
Bansal, N., Karpawich, P. P., & Sriram, C. S. (2017). Junctional tachycardia in a child with non-rheumatic fever streptococcal pharyngitis. Cardiology in the Young, 27(5), 985–989. https://doi.org/10.1017/S1047951116002638
Hammour, K. A., Jalil, M. A., & Hammour, W. A. (2018). An exploration of parents’ knowledge, attitudes and practices towards the use of antibiotics in childhood upper respiratory tract infections in a tertiary Jordanian Hospital. Saudi Pharmaceutical Journal, 26(6), 780–785. https://doi.org/10.1016/j.jsps.2018.04.006
Knight, Z. G. (2017). A proposed model of psychodynamic psychotherapy linked to Erik Erikson’s eight stages of psychosocial development. Clinical Psychology & Psychotherapy, 24(5), 1047–1058. https://doi.org/10.1002/cpp.2066
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