FNP 590 FINAL SOAP PRD IMMERSION
SUBJECTIVE:
ID: K.M. DOB 12/1/2005, is a 14-year-old female, Caucasian American of Northern European descent, who
presents to clinic for a well child exam with her mother, Jennifer. She is alert and oriented to person and
appears to be knowledgeable and a reliable historian of her own health history.
CC: “A routine well-child visit and for an epi pen because it has expired.”
HISTORY OF PRESENT ILLNESS (HPI): Last physical exam 01/2019. No recent lab work. No recent
immunizations. Flu shot not received this season. Last dental exam 1/2020. Last eye and hearing exam
01/2019. No patient complaints.
PAST MEDICAL HISTORY:
Medical Problem list: Left clavicular fracture 6/2008.
Surgeries and hospitalizations: Denies surgical history. Denies hospitalizations.
Medications: Daily multi vitamin; Epi pen 0.30mg/0.30ml, prefilled autoinjector IM, PRN for anaphylaxis.
Denies use of other OTC, RX or supplements.
Allergies: Reports severe nut allergy; has Epi pen; never needed it. Denies seasonal, environment, drug, bee,
or latex allergies.
Immunizations: Mother reports immunizations are up to date; except HPV; declined. Flu shot requested
today (1/24/2020).
-Polio (01/19/2011), (04/26/2011), (06/17/2011)
-Diphteria/tetanus/pertussis (DTaP) (01/19/2011), (04/26/2011), (06/17/2011), (04/17/2012)
-Measles, mumps, rubella (MMR) (12/07/2011)
-Haemophilus influenza type B(Meningitis)(HIB) (01/19/2011, (04/26/2011), (06/17/2011), (12/07/2011)
-Hepatitis B: (12/01/2010), (01/19/2011), (04/26/2011)
-Varicella: (12/07/2011)
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00
https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/
, -Hepatitis A: (12/07/2011)
-Influenza: (12/07/2011)
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00
https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/
SUBJECTIVE:
ID: K.M. DOB 12/1/2005, is a 14-year-old female, Caucasian American of Northern European descent, who
presents to clinic for a well child exam with her mother, Jennifer. She is alert and oriented to person and
appears to be knowledgeable and a reliable historian of her own health history.
CC: “A routine well-child visit and for an epi pen because it has expired.”
HISTORY OF PRESENT ILLNESS (HPI): Last physical exam 01/2019. No recent lab work. No recent
immunizations. Flu shot not received this season. Last dental exam 1/2020. Last eye and hearing exam
01/2019. No patient complaints.
PAST MEDICAL HISTORY:
Medical Problem list: Left clavicular fracture 6/2008.
Surgeries and hospitalizations: Denies surgical history. Denies hospitalizations.
Medications: Daily multi vitamin; Epi pen 0.30mg/0.30ml, prefilled autoinjector IM, PRN for anaphylaxis.
Denies use of other OTC, RX or supplements.
Allergies: Reports severe nut allergy; has Epi pen; never needed it. Denies seasonal, environment, drug, bee,
or latex allergies.
Immunizations: Mother reports immunizations are up to date; except HPV; declined. Flu shot requested
today (1/24/2020).
-Polio (01/19/2011), (04/26/2011), (06/17/2011)
-Diphteria/tetanus/pertussis (DTaP) (01/19/2011), (04/26/2011), (06/17/2011), (04/17/2012)
-Measles, mumps, rubella (MMR) (12/07/2011)
-Haemophilus influenza type B(Meningitis)(HIB) (01/19/2011, (04/26/2011), (06/17/2011), (12/07/2011)
-Hepatitis B: (12/01/2010), (01/19/2011), (04/26/2011)
-Varicella: (12/07/2011)
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00
https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/
, -Hepatitis A: (12/07/2011)
-Influenza: (12/07/2011)
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00
https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/
