Soap Note

Name: M. O. Date: 05/21/18
Sex: MaleAge/DOB/Place of Birth: 8 Y/O /04-20-2010/Miami, Florida
SUBJECTIVE
Historian: Dad Present Concerns/CC:   “He hurt his right arm.”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)   Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.
HPI: (must include all components)   8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.
Medications: (List with reason for med )   None.
PMH:   Allergies: NKDA   Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None  Immunizations: Updated
Family History (Please identify all immediate family)   Father alive and well, mother alive and well.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status   He lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.
ROS
General   Denies, headache, chills, myalgia.Cardiovascular   Denies chest pain/discomfort, heart problems
Skin   Denies rash or lesions.  Respiratory   Denies cough, difficulty breathing, wheezing.
  
Eyes   Denies discharge from eye, redness, or painGastrointestinal   Denies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.
Ears   Denies pain or dischargeGenitourinary/Gynecological   Denies dysuria or changes in urinary pattern.    
Nose/Mouth/Throat   Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing  Musculoskeletal   Reports injury and pain to left arm
Breast   Denies pain or tenderness  Neurological   Denies loss of consciousness, dizziness, headache, or alteration in mental status
Heme/Lymph/Endo   Denies weight loss, activity intolerance, heat or cold intolerance  Psychiatric   Denies depression, anxiety, or suicidal ideation
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 30.3 kgTemp 98.9 FBP 97/59 mmHg
Height 50 in BMI: 18.74Pulse 100 x’Resp 20 x’     Sp02
General Appearance and parentchild interaction:   No acute distress, well-developed, well nourished, alert.          
Skin   Skin pink, warm, and dry, no rashes or lesions noted.
HEENT   Head normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.
Cardiovascular   S1S2 audible. Regular rate and rhythm. No murmurs.
Respiratory   Lungs clear, good air exchange, no wheezes or rales
Gastrointestinal   Abdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly
Breast   Deferred
Genitourinary   Bladder is non-distended; no CVA tenderness, external and internal genitalia not examined.
Musculoskeletal   Limited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.
Neurological   Alert, moves all extremities spontaneously  
Psychiatric    Age appropriate development.
In-house Lab Tests – document tests (results or pending)   Right wrist x-ray – closed fracture at distal radius
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)      
Diagnosis
1.  Closed fracture of distal end of right radius – S69.91XAPertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-rayPertinent negatives –  no obvious deformity, no swellingRationale – Limited ROM following injury or trauma to the arm suggest possible fracture. 2. Other specified sprain of right wrist, initial encounter –  S63.591A Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROMPertinent negatives – no obvious deformity, no swellingRationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain. 3. Dislocation of right wrist – M24.331 Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROMPertinent negatives – no obvious deformity, no swellingRationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation. Primary diagnoses: Closed fracture of distal end of right radius – S69.91XA   PLAN including education Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note providedAdminister Tylenol or Motrin every 4-6 hours as needed for pain.Follow-up with Orthopedics, copy of x-ray CD provided    
 
  References   Arora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.3928/00904481-20140417-12

*ALL references must be Evidence Based (EB)

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