(SOAP NOTE) NR511 Jo AGE 5 FEMALE (CC
Difficulty to get children to go to bed and stay in bed)
Jo AGE 5 YEARS FEMALE
Subjective
Chief complaint: difficult to get the children to go to bed at night and stay in bed
History of present illness (HPI): The mother denies any recent illnesses in either child and
reports they are here for their check-up. She does report that since moving in with her parents
recently, it has been difficult to get the children to go to bed at night and stay in bed and
expresses extreme frustration with this. Jo has been getting up to play in the room at night and
She reports that they are eating three meals per day and two snacks, one at bedtime and one in
the afternoon between lunch and dinner. Riley is still taking infant formula. Mother brushes their
teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at
home. She also verbalizes extreme concern of their impending loss of health insurance.
Past Medical History/Birth history: Full-term gestation, born cesarean section, weight. 7 pounds
4 ounces. There were no complications in pregnancy, but the mother did smoke 1 pack-per-day
throughout pregnancy. There were no hospitalizations—NKDA
Nutrition: The daily medication was chewable children’s multivitamin with iron. They eat three
meals and two snacks. There is a great deal of juice, soda, and processed or quick foods given
in the house.
Immunizations: Birth Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP,
COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella,
Hep A, PCV 13, 18 months – DtaP, Hep A
Family History: They are maternal and paternal smokers. The mother has been one since age
22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no
diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a
history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension,
hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died
in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and
lives in a large urban city in the Midwest with her family, and she is in good health but also had
PCOS and difficulty conceiving. Other family members died of old age. She is unaware of
paternal familial health history.
Social and environmental history: Both children currently live with their mother and maternal
grandparents for the last 8 weeks. Their father is involved but lives several hours away where
he works. Jo will be starting kindergarten this fall in the community’s elementary school.
Cultural history: They are Latin American in descent, the grandparents emigrated from Cuba in
the 1970s. Jo and Riley are United States soil.
Review of Systems:
Neurologic: Frequent morning headaches? Do you have any developmental concerns? Is she
hyperactive while at school? Any difficulties paying attention? Irritability of mood swings
throughout the day?
Head/Eyes/Ears/Nose/Mouth/Throat: Does she have enlarged tonsils? Frequent colds or sore
throats? Frequent ear infections? Changes in vision? Changes in hearing?
Integumentary: Any rashes, reports of itching, change in pigmentation, excessive moisture or
dryness, presence of wounds, presence of invasive devices, alterations in texture, changes in
hair growth, texture or loss, nail changes, tenderness, no swelling
1|Page
, Cardiovascular: cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest
pain, palpitations
Respiratory: Does she mouth breath or have trouble breathing through the nose? Asthma?
Genitourinary: Any urgency, frequency of urination at night? Any blood in the urine?
Endocrine: Have you noticed excessive weight gain? Or failure to gain weight? Any increase in
hunger, thirst, urination or problems with hot or cold environments?
Gastrointestinal: Does she have difficulty swallowing and/or drooling? Have you had any
complaints of nausea vomiting or stomach acid reflux? Do any of the following occur: changes
in appetite, dysphagia, and indigestion, food intolerances to milk products, abdominal pain,
heartburn, denies nausea, denies vomiting, denies hematemesis, no jaundice, or denies
constipation?
Musculoskeletal: Does she sleep walk? Any muscular disorders?
Hematologic: Any prevalent genetic disease? Any bleeding problems in skin; excessive bruising.
Exposure to toxins, any blood transfusions.
Objective
Vital signs: height: 110 centimeters 75th percentile; weight: 29 kilograms, BMI 24.0 (Normal 18.5-
25) BMI percentile is 95% B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, nonlabored,
SpO2: 99%
General: Cooperative, talkative, appropriate; HEENT: head normocephalic atraumiatic, hair thick
and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact;
fundoscopic exam unremarkable; vision by Snellen exam 20/40 in each eye, 20/30 together;
tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent,
unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first
molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o
lymphadenopathy; thyroid small, firm, equal bilateral
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no
masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal; GU – labia
majora and minora intact, no erythema or discharge. Tanner 1 breasts and pubic area.
Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left
with any balance, tries but tumbles; able to balance on each leg for 10 seconds.
Cognitive Development: Able to state name and age; can write her own name; able to recall three
friends names; knows all colors and can count to 13; dresses herself and has control of bowels
and bladder; verbal throughout exam; all of speech clear and recognizable
Assessment
Primary Diagnosis
1. Wellness Child Exam ICD 10: Z00.129. In the wellness child exam the child is
screened for immunization, growth and development, disease prevention and health
promotion. Secondary Diagnosis
2. Obesity ICD (10: E66.1) - Obesity according to the CDC (2017) is equal to or greater
than the 95th percentile of a growth chart. The patient’s current BMI is 24% which places
her above the 99th percentile for girls aged 5.
2|Page
Difficulty to get children to go to bed and stay in bed)
Jo AGE 5 YEARS FEMALE
Subjective
Chief complaint: difficult to get the children to go to bed at night and stay in bed
History of present illness (HPI): The mother denies any recent illnesses in either child and
reports they are here for their check-up. She does report that since moving in with her parents
recently, it has been difficult to get the children to go to bed at night and stay in bed and
expresses extreme frustration with this. Jo has been getting up to play in the room at night and
She reports that they are eating three meals per day and two snacks, one at bedtime and one in
the afternoon between lunch and dinner. Riley is still taking infant formula. Mother brushes their
teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at
home. She also verbalizes extreme concern of their impending loss of health insurance.
Past Medical History/Birth history: Full-term gestation, born cesarean section, weight. 7 pounds
4 ounces. There were no complications in pregnancy, but the mother did smoke 1 pack-per-day
throughout pregnancy. There were no hospitalizations—NKDA
Nutrition: The daily medication was chewable children’s multivitamin with iron. They eat three
meals and two snacks. There is a great deal of juice, soda, and processed or quick foods given
in the house.
Immunizations: Birth Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP,
COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella,
Hep A, PCV 13, 18 months – DtaP, Hep A
Family History: They are maternal and paternal smokers. The mother has been one since age
22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no
diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a
history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension,
hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died
in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and
lives in a large urban city in the Midwest with her family, and she is in good health but also had
PCOS and difficulty conceiving. Other family members died of old age. She is unaware of
paternal familial health history.
Social and environmental history: Both children currently live with their mother and maternal
grandparents for the last 8 weeks. Their father is involved but lives several hours away where
he works. Jo will be starting kindergarten this fall in the community’s elementary school.
Cultural history: They are Latin American in descent, the grandparents emigrated from Cuba in
the 1970s. Jo and Riley are United States soil.
Review of Systems:
Neurologic: Frequent morning headaches? Do you have any developmental concerns? Is she
hyperactive while at school? Any difficulties paying attention? Irritability of mood swings
throughout the day?
Head/Eyes/Ears/Nose/Mouth/Throat: Does she have enlarged tonsils? Frequent colds or sore
throats? Frequent ear infections? Changes in vision? Changes in hearing?
Integumentary: Any rashes, reports of itching, change in pigmentation, excessive moisture or
dryness, presence of wounds, presence of invasive devices, alterations in texture, changes in
hair growth, texture or loss, nail changes, tenderness, no swelling
1|Page
, Cardiovascular: cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest
pain, palpitations
Respiratory: Does she mouth breath or have trouble breathing through the nose? Asthma?
Genitourinary: Any urgency, frequency of urination at night? Any blood in the urine?
Endocrine: Have you noticed excessive weight gain? Or failure to gain weight? Any increase in
hunger, thirst, urination or problems with hot or cold environments?
Gastrointestinal: Does she have difficulty swallowing and/or drooling? Have you had any
complaints of nausea vomiting or stomach acid reflux? Do any of the following occur: changes
in appetite, dysphagia, and indigestion, food intolerances to milk products, abdominal pain,
heartburn, denies nausea, denies vomiting, denies hematemesis, no jaundice, or denies
constipation?
Musculoskeletal: Does she sleep walk? Any muscular disorders?
Hematologic: Any prevalent genetic disease? Any bleeding problems in skin; excessive bruising.
Exposure to toxins, any blood transfusions.
Objective
Vital signs: height: 110 centimeters 75th percentile; weight: 29 kilograms, BMI 24.0 (Normal 18.5-
25) BMI percentile is 95% B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, nonlabored,
SpO2: 99%
General: Cooperative, talkative, appropriate; HEENT: head normocephalic atraumiatic, hair thick
and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact;
fundoscopic exam unremarkable; vision by Snellen exam 20/40 in each eye, 20/30 together;
tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent,
unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first
molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o
lymphadenopathy; thyroid small, firm, equal bilateral
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no
masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal; GU – labia
majora and minora intact, no erythema or discharge. Tanner 1 breasts and pubic area.
Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left
with any balance, tries but tumbles; able to balance on each leg for 10 seconds.
Cognitive Development: Able to state name and age; can write her own name; able to recall three
friends names; knows all colors and can count to 13; dresses herself and has control of bowels
and bladder; verbal throughout exam; all of speech clear and recognizable
Assessment
Primary Diagnosis
1. Wellness Child Exam ICD 10: Z00.129. In the wellness child exam the child is
screened for immunization, growth and development, disease prevention and health
promotion. Secondary Diagnosis
2. Obesity ICD (10: E66.1) - Obesity according to the CDC (2017) is equal to or greater
than the 95th percentile of a growth chart. The patient’s current BMI is 24% which places
her above the 99th percentile for girls aged 5.
2|Page
