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) -Pneumococcal vaccine: (01/19/2011) (04/26/2011) (06/17/2011) (12/07/2011) -Rotavirus: (01/19/2011) (04/26/2011) (06/17/2011) Health Maintenance Activities: -Chemical History: Mother not present for this part of exam. Denies use or thoughts of using tobacco (including smokeless & vaping) and is not around second hand smoke. Denies use or thoughts of using drugs. Denies use or thoughts of alcohol consumptions. Pt reports that she and her friends have never tried any of the above chemicals and she is not exposed to them at home. -Exercise/Diet: Cross fit 3-4xweek and plays outside with friends. Eats 3 well balanced meals a day plus healthy snack. Meals contain fruit, vegetables, protein, low sugar, and carbohydrates. Mom packs school lunch. No caffeine for 1 year, 1/2019. Fast food 1-3 x week. Drinks 3 glasses of milk and plenty of water a day. Screen time limited to 1hr a day. -Sleep/Stress: Mother not present for this part of exam. Denies daily stress. Reports situational stressors i.e. testing at school. Denies feeling depressed, down or blue. Reports 9 hours a sleep a night 7 days a week. Denies insomnia, nightmares, or sleep disturbances. Family History: Per mother: PGF, age 72: HTN, cataracts, DM2, obesity PGM, age 69: Hypothyroidism, osteoporosis Father, age 70: HTN MGF, age 68: heavy smoker, COPD, CABG MGM, age 60: HTN, Type II DM Father, age 40: None Mother, age 39: asthma as a child Brother, age 5: asthma, seasonal allergies SOCIAL HISTORY: -OCCUPATION: Student -EDUCATION: 8th grade, straight A’s. Enjoys reading, crafts, playing the guitar and hanging out with friends and family. -HOUSING: Lives in military provided home in a “good neighborhood” with her with mom, dad, 5yr old brother and dog. -MARITAL HISTORY: Single. -SEXUAL/REPRODUCTIVE: Mother not present for this part of exam. Pt denies initial menarche. Denies having sex or the desire for sexual activity currently. Reports her friends are not sexually active. Denies having questions or concerns about sex or safe sex. Feels comfortable talking with mother. Plans on abstinence for birth control. Denies boyfriend. Denies history of unwanted touch or sexual activity. Verbalizes understanding that NO means NO and where to go if she needs help or has further questions. SOCIAL SUPPORT/SPIRITUAL AFFILIATION: Social support system is family and friends. Pt reports “safe and well-supported” at home and school. Spiritual affiliation not assessed. SAFETY: Pt reports: rides bike with helmet; trampoline use with safety net; wears seat belt; no guns in home; no pool on property. Denies exposure to violence. Mild temper and prefers to walk away from violent situations. Denies being bullied. Reports feeling safe in her current environment. Denies feeling peer pressured and states she has the strength to say “NO”. REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies fever, chills, changes in appetite, fatigue, nausea or vomiting. EYES: Denies corrective eye wear, blurred vision, changes in vision, discharge or redness. Last eye exam 01/2019. EARS, NOSE, MOUTH/THROAT: Denies hearing loss, tinnitus, vertigo, discharge, and earache. Denies rhinorrhea, stuffiness, sneezing, and epistaxis. Denies allergies other than nuts. Denies sore throat, hoarseness, pain or difficulty swallowing. Last dental exam 1/2020. Brushes teeth 2xday and flosses daily. No cavities or fillings. No orthodontics. CARDIOVASCULAR: Denies murmurs, angina, palpitations, orthopnea, dyspnea, edema, or dyspnea. RESPIRATORY: Denies shortness of breath, wheezing, cough, or sputum. Denies hemoptysis, pneumonia, tuberculosis, asthma.