Soap note for 13-year old healthy boy

Name:

Institution:

Patient – 13-year-old boy who is healthy, ad only takes a gummy vitamin daily 

Chief complaint: routine skin and abdominal checkup 

Subjective

History of present illness: the patient wants a routine check on his skin and abdomen. The patient has no health issues now, apart from some bloating in the abdomen, probably caused by the gummy vitamins he takes regularly. The bloating occurs after lengthy chewing of the gummy vitamins. The patient has some ace o the face. 

Medical hx – no past hospitalization or medication; no past surgeries. 

Family history – 13 year old lives with parents who are alive and well, and is currently at school.  

Social history – no past drug use reported no allergies to medications. Immunization is up to date.  

Review of systems: Constitutional: no weakness, fatigue or fever, or night sweats reported. 

No scalp pain, thinning hair or hair loss. 

Eyes: denies eye pain, vision disturbances, and eye pressure ear: no pain, no hearing disturbances, tinnitus, or discharge. Nose: no congestion or discharge, no bleeding, no pain.

Mouth and throat: denies cough. Denies painful or sore throat neck: no swollen neck glands.

Respiratory: no cough denies sob and wheezing, no painful breathing. 

Cardiac: no cp, denies sob, denies palpitations, and denies dizziness. 

gi: no n/v/d, reports bloated stomach, but no pain, cramping and discomfort. No changes in bowel patterns, no blood in stool 

GU: no urgency, no frequency, no burning with urination. 

Musculoskeletal: no joint pain, stiffness, or muscle pain hematologic: no bruising or bleeding.

Skin: Ace o the face, but no rash, irritations, or redness 

Neurology: no complaints of ha, numbness, tingling, dizziness, or lightheadedness. Denies tremors or involuntary movements. 

Mental health: denies depression and anxiety. 

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Objective 

Vital signs: bp 106/61, heart rate – 71, respiratory rate – 24, Oxygen saturation – 100%. Temperature – 98.0 degrees Fahrenheit. 100 pounds (weight), height – 4’8”. 

BMI – 22.00 

Urinalysis: +leuks +nits –

Physical exam: head: head and scalp: normal hair distribution 

Eyes: eom intact, red reflex visualized, 

Perrla, no cataracts noted b/l, eyelids without redness or swelling 

Ears: no tenderness on palpation of tragus, no erythema or effusion. Tympanic membrane normal. 

Nose: no erythema or swelling of turbinates, no discharge and crusting seen in bilateral nares

Throat and mouth: no pharyngeal erythema and uvula midline. No ulcers noted. No foul odor from mouth, no tonsillar enlargement without exudates. Neck is supple without tender cervical nodes, no nuchal rigidity and thyroid tissue firm pliable and non-tender.

Thorax and lungs: no cough, b/l bs clear in all fields, respirations are unlabored, no use of accessory muscles. No pain related to respiration cv: 

hrr, no murmur noted. +pulses in all four extremities. 

Assessment

Nursing diagnosis – impaired skin integration, characterized by acne on face. 

Differential diagnosis - not applicable. 

Plan

Medication: Apply adapalene on the face, twice a day after washing the face 

Education: avoid chewing on the gummy vitamin for too long, to avoid bloating 

Evaluation – review condition every week to assess progress.