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WELL EXAM CHILD SOAP
Monika Checa
United States University
MSN 572: Advanced Health and Physical Assessment Across the Lifespan
Dr. Todorova
May 14th, 2021
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:57:54 GMT -05:00
https://www.coursehero.com/file/95597178/SOAPWELLNESSCHILDIMMERSIONWEEK2-3docx/
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Health History SOAP
SUBJECTIVE:
ID:
J.M, age 10, Caucasian female, DOB 01/14/12011. The patient is accompanied by her mother
and the patient and mother are reliable historians. Patient presents to the clinic for a wellness
check and no current concerns currently. Patient is alert and oriented and answers questions
appropriately. Patient is accompanied by her mother during exam. The patient lives at home with
Her Father, Mother and 5 siblings. Resides is a single-story home. Last wellness exam
05/07/2019. Patient reports no health issues.
CC:
“I am here for my annual wellness check.”
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 10-year-old female who presents to the clinic for an annual wellness exam.
Patient reports his last wellness exam was on 05/07/2019. Patient does not take prescription
medications, only takes an over-the-counter multivitamin. Patient has a severe allergy to peanuts
and has an Epi pen that is expired. Patient reports last year the peanut allergy cause her sever
wheezing that sent her to the emergency room. Patient does not recall recent lab work. Patient
reports no health issues or concerns currently. Patient is alert and oriented and answers
appropriately.
PAST MEDICAL HISTORY:
Fractured clavicle at age 2 ½ years old.
Peanut allergies, 2020
PAST MEDICAL PROCEDURES:
Denies surgeries.
MEDICATIONS:
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:57:54 GMT -05:00
https://www.coursehero.com/file/95597178/SOAPWELLNESSCHILDIMMERSIONWEEK2-3docx/
WELL EXAM CHILD SOAP
Monika Checa
United States University
MSN 572: Advanced Health and Physical Assessment Across the Lifespan
Dr. Todorova
May 14th, 2021
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:57:54 GMT -05:00
https://www.coursehero.com/file/95597178/SOAPWELLNESSCHILDIMMERSIONWEEK2-3docx/
, 2
Health History SOAP
SUBJECTIVE:
ID:
J.M, age 10, Caucasian female, DOB 01/14/12011. The patient is accompanied by her mother
and the patient and mother are reliable historians. Patient presents to the clinic for a wellness
check and no current concerns currently. Patient is alert and oriented and answers questions
appropriately. Patient is accompanied by her mother during exam. The patient lives at home with
Her Father, Mother and 5 siblings. Resides is a single-story home. Last wellness exam
05/07/2019. Patient reports no health issues.
CC:
“I am here for my annual wellness check.”
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 10-year-old female who presents to the clinic for an annual wellness exam.
Patient reports his last wellness exam was on 05/07/2019. Patient does not take prescription
medications, only takes an over-the-counter multivitamin. Patient has a severe allergy to peanuts
and has an Epi pen that is expired. Patient reports last year the peanut allergy cause her sever
wheezing that sent her to the emergency room. Patient does not recall recent lab work. Patient
reports no health issues or concerns currently. Patient is alert and oriented and answers
appropriately.
PAST MEDICAL HISTORY:
Fractured clavicle at age 2 ½ years old.
Peanut allergies, 2020
PAST MEDICAL PROCEDURES:
Denies surgeries.
MEDICATIONS:
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:57:54 GMT -05:00
https://www.coursehero.com/file/95597178/SOAPWELLNESSCHILDIMMERSIONWEEK2-3docx/
