Acne Soap Note In Teenager
Delete all text in red – these are instructions and not part of the SOAP document.
Well child SOAP note- Infant and Child examples
Requirement:
· APA format
· Intext citation
· References at least 4 high-level scholarly reference per post within the last 5 years in APA format.
· EACH differential diagnostic gets 1 reference
· Include Immunization chart (age and gender appropriate)
· Include Growth Chart (age and gender appropriate)
· Plagiarism free.
· Turnitin receipt.
ID: Patients name: ____, Age: __16____, Race: _____, Gender: __male____ Date of Birth: _______
Reliable Historian: _______
*Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.
SUBJECTIVE:
CC: “ I have a lot of pimples in my face”
History of Present Illness (HPI)
In paragraph format, including at the minimum OLDCARTS. Please start with demographics: V.L. is a 12-month-old Hispanic male comes to the clinic today with his mother with complaint of ______
Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms, Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.
Past Medical History (PMH):
If No prior medical history (first time patient- mention it; typically, with infants)
Surgeries:
Hospitalizations:
Medical problem list:
Medications:
Allergies:
Immunizations: All immunizations are up to date. Immunizations due today include Hepatitis A, MMR and Varicella vaccine
| Immunization | Total Doses | Up to Date |
| HepB | 3 | Yes |
| Rotavirus | 2 | Yes |
| DTaP | 5 | Yes |
| Hib | 3 | Yes |
| PCV13 | 3 | Yes |
| IPV | 4 | Yes |
| MMR | Due | |
| Varicella | Due | |
| Hepatitis A | 2 | Yes |
| Pfizer COVID-19 | 2 | Yes |
| Influenza | 2 | Yes |
Developmental Milestones EXAMPLE-
Social: EX: V.L. is very friendly and get along well with other kids of his age.
Language: EX: V.L. can says words like mama, papa and waves bye-bye.
Speech: EX: His speech is clear and appropriate for his age.
Cognitive: EX: He can recognize some colors and shapes. He picks up toys and puts them in the box.
Motor: EX: he interacts and plays with other children; imaginative play; draws recognizable pictures; Walking and climbing, skips on 1 foot, climbs stairs alternating feet without support (Bright Futures, 2017)
Self help: EX: Potty trained at 2 ½ years old, regular bowel movements; brushes his teeth; dresses and undresses without help
Developmental Milestones FOR INFANTS ONLY: EXAMPLE-
Social: EX: V.L. is very friendly and get along well with other kids of his age.
Language: EX: V.L. can says words like mama, papa and waves bye-bye.
Speech: EX: His speech is clear and appropriate for his age.
Cognitive: EX: He can recognize some colors and shapes. He picks up toys and puts them in the box.
Gross motor: EX: V.L. can walk few steps without support. He picks up toys and puts them in the box.
Fine motor: EX: Can hold pencil with his fist and scribbles in the paper (Misirliyan et al., 2023).
Family History
Mother:
Father:
Siblings:
Maternal grandmother:
Maternal grandfather:
Paternal grandmother:
Paternal grandfather:
Social History
Living condition: V.L. lives in a single-family home with his parents and brother. He stays home with his mother. He doesn’t go to any day care or play school.
Financial resources: Fathers works as engineer, mother works part-time as a teacher; They have health insurance
School performance: has peer interactions
Safety: When riding in a motor vehicle, V.L. is always buckled up and is seated in a car seat rear facing. There is no pool or gun at home. Medication cabinets are always locked. Has a pet cat.
Diet: drinks Enfamil baby formula and water. He also eats rice cereal and pureed fruits and vegetables.
Exercise: He is very active. Likes to plays with his brother at home. He plays with kids of his age when he goes to the playground.
Sleep: sleeps through the night. He sleeps 10-12 hours at night and 2-3 hours in the afternoon when he naps.
Behavior: Normal age-appropriate behavior.
Exposure: No exposure to second hand smoking, alcohol or any other drug use in the family.
Screen time: 45 minutes daily
Spiritual Affiliation: Christian. Goes to church on Sundays.
Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)
Birth History: (ONLY FOR INFANT) EXAMPLE-
Gestation: Ex: Full term at 39 weeks
Delivery Method: Ex: Spontaneous vaginal delivery
Birth Complications: Ex: None
Birth weight: Ex: 7 pounds, 7 ounces
Birth Length: Ex: 21.5 inches
Breastfed: Ex: Yes. Until 8 months
Review of Systems (ROS): (write out by system): Comprehensive ( >10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines
Constitutional: obese child.
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
OBJECTIVE
Vital Signs: (be sure to include percentiles for peds)
Temperature:
HR:
BP
RR:
SpO2:
Pain:
Height: 31.5 inches (98th percentile- See the plotted growth chart below)
Weight: 10.5 kg (75th Percentile- See the plotted growth chart below)
Head Circumference: 18.5 inches (75th Percentile-See the plotted growth chart below)
BMI: 16.14- Normal
Physical Exam (write out by system):
General Survey:
Head:
Eyes:
Ears:
Nose:
Throat
Neck:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary: EX: No diaper rash was observed, and the female genitalia were normal. Tanner first stage.
Musculoskeletal: EX: Able to move all extremities freely. Has begun to walk normally for his age. Pink, warm, dry, and flawless skin. Ecchymosis, rashes, moles, or lesions were not present.
Neuro: EX: conscious and aware. Smiles and acknowledges his name. Meeting developmental goals.
Psych: EX: Pleasant personality, bit timid with healthcare provider, but age appropriate. Age-appropriate interaction with mother.
ASSESSMENT
(you will often have more than one diagnosis/problem, but do the differential on the main problem)
Differential Diagnosis (with a brief rationale, and references for each one:
1. Acne vulgaris:
2. Sebaceous hyperplasia
3. Folliculitis
Final Diagnosis Acne vulgaris
PLAN (4 pronged-plan for each problem on the problem list) use clinical guidelines to develop treatment plans for your patients
Diagnostics:
Treatment: (please use Guidelines reference) use clinical guidelines to develop treatment plans for your patients
Education/ Anticipatory Guidance:
EX:
1. Health/Developmental – Encourage parents to keep developing nap and bedtime routines creating a tooth-brushing regimen, and scheduling dental appointments. Remind parents to employ constructive punishment and to avoid watching TV or other media.
2. Safety – Inform parents on how to use a car seat correctly, how to remove or lock up poisonous items to prevent accidental poisonings, where to find the poison control number, how to stay safe around water, how to use sunscreen and other protective equipment, how to avoid choking hazards with pets, how to install gates near stairs, and other ways to make the home a safer place.
3. Diet – Promote the benefits of following a balanced diet, which should include three meals and two to three snacks per day, as well as the promotion of self-feeding and the avoidance of tiny, hard foods (Philips et al., 2019).
EX: Education to the parents should be the safety and milestones he will continue to have. Some new motor milestones may include balancing on foot, hops (Bright Futures). Some language milestones may include counting up to 10, naming 4 or more colors (Bright Futures). He may also draw a person with at least 6 body parts and copy squares and triangles (Bright Futures).
Follow Up: EX: Follow up with immunization, hearing, oral health, and vision. Order for bloodwork. Maintain appropriate diet, and exercise for his age group. Such as implementing vegetables and fruits into diet. As for exercise if he plays a sport it should be at most four hours per week/
EX: Administer scheduled vaccinations: Hepatitis A, MMR, Varicella according to CDC vaccine schedule for infants.
Referral to dentist- If not established with one already. This is for dental checkups and routine clean ups.
Return in three months for a 15-month well-child exam and vaccines.
Follow up as necessary if sick or any other issues.
Prescriptions two refills on epi pen autoinjector; Dose 0.15mg (0.3 ml)
Side effects: weakness, shaking, fear, dizziness headache, anxiety, paleness, throbbing, and tenseness (How EpiPen works)
List plan under each Diagnosis.
Example
1: Morbid Obesity BMI XX.X (E66.01)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
2: T2 Diabetes with diabetic neuropathy (E11.21)
A: Repeat A1C in 3 months
B. Increase Metformin to 1000mg BID #180, refills: 3
C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)
D: Daily blood glucose check in the am and when sick
E. Return to clinic in 3-4 months to reassess
EXAMPLE CHART: for (2-20 years) (MALE)
EXAMPLE: for BABIES/INFANTS (birth-24 months)
References
CDC Growth Charts – Centers for Disease Control and Prevention. Center for Disease Control.
(2022). https://www.cdc.gov/growthcharts/data/set1clinical/set1color.pdf
Centers for Disease Control and Prevention. (2022). Birth-18 years immunization
schedule. Centers for Disease Control and Prevention.
https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
Centers for Disease Control and Prevention. (2022). Developmental monitoring and
screening. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/childdevelopment/screening.html
Phillips, S. P., Jiang, M., Lakkadghatwala, R., & Wang, S. (2019).
Assessing wellness in the well-child check: What about social and emotional development. Canadian family physician Medecin de famille canadien, 65(3), e113–e120.
Misirliyan, S. S., Boehning, A. P., & Shah, M. (2023).
Development Milestones. In StatPearls. StatPearls Publishing.