FNP 590 FINAL SOAP PRD IMMERSION

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) -Hepatitis A: (12/07/2011) -Influenza: (12/07/2011)