SOAP Note: Immunization Assignment Paper

SOAP Note: Immunization Assignment Paper

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Patient information

Patient initials: W.E. Age: 6-month-old         Gender: Male                           Race: Caucasian

S

CC: ‘Six-month vaccination appointment.’

HPI: W.E., a six-month-old Caucasian male, was presented to the health center by his mother for his six-month immunization appointment. There were no reports of fever, sore throat, or runny nose. His mother also denied any food or medication allergies.

Current medication: Seven Seas 2,5ml P.O. QD

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PMH: none

Allergy: NKDFA

Immunization: up-to-date and was brought for his six-month shots.

Family history: no significant family history was reported.

Social history: The patient is the first child of the mother. They live in a safe apartment. His mother stated that he has not yet been introduced to solid foods and that she smokes more regularly but never in the vicinity of the child. SOAP Note: Immunization Assignment Paper

ROS

General: -ve fever, fatigue and loss of appetite, and weight loss.

HEENT: negative for loss of vision or hearing.

CV: -ve for chest pain

Resp: -ve for cough and night sweats

GI/GU: -ve for N/V/D, dysuria, and polyuria

MSK: -ve for muscle pain

Skin: -ve for skin rash

Endocrine: -ve for cold or heat intolerances

O

PE:

Vts: Temp 37.3 rectal P.78   RR: 20 SpO2 98% Wt. 17lb Ht. 66 cm. Head circumferences 40.2

General: he is well-developed, well-nourished, and appears well hydrated.

HENT: normocephalic and atraumatic. EOMI. PERRLA (Jarvis,2018).

CVS: Quiet precordium, no thrills. RRR.

Respiration: symmetric chest expansion

Abdomen: soft and non-tender. Bowels sound normoactive.

Genitalia: circumcised. Bilateral descended testes.

Extremities: Warm, no clubbing. Good skin turgor.

Neurological: normal clonus in both feet. Normal Gallant reflexes

A:

Immunization

P.

Medication: Dtap, Hib, and PCV13 shots to be administered to the child through I.M. (Tiley et al.,2018).

Patient education: The mother should be advised to give her baby Calpol 100ml for pain at the injection site. She should be advised accordingly on possible side effects such as fever.

Follow-up: Patient to be returned to clinic as needed

References

Tiley, K. S., White, J. M., Andrews, N., Ramsay, M., & Edelstein, M. (2018). Inequalities in childhood vaccination timing and completion in London. Vaccine, 36(45), 6726-6735.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences. SOAP Note: Immunization Assignment Paper