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.