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FNP 590 FINAL SOAP PRD IMMERSION

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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 re...

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  • April 30, 2022
  • 10
  • 2021/2022
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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)
This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00


https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/

, -Hepatitis A: (12/07/2011)

-Influenza: (12/07/2011)




This study source was downloaded by 100000834306259 from CourseHero.com on 04-29-2022 11:50:52 GMT -05:00


https://www.coursehero.com/file/62574649/Final-SOAP-PED-immersiondocx/

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