Continued: SOAP NOTE 5

Objective: Physical Examination

Vital Signs:

Temp: 98F axillary, HR: 73, RR: 18, BP: 110/74, O2 Sat 98% RA

Weight: 128lbs (61st percentile) Height: 65in (63rd percentile)

BMI: 21.3% (55th percentile)

GENERAL APPEARANCE

Patient is a 17-year-old Caucasian female presenting with mother for a well child examination.

Patient appears well groomed and dressed appropriately for season. Appears well nourished.

Upon entering the room, the sitting in a chair looking at her cell phone. No apparent distress.

MENTAL STATUS

Patient is alert and oriented to person, place, and time. She speaks in full sentences with clear

speech. Answers questions appropriately. Appropriate affect.

SKIN/HAIR/NAILS

Skin is dry, warm, and intact. Skin is smooth. Skin color is fair and appropriate for race. Skin

turgor is elastic. No lesions or other discoloration noted. Nails of fingers and toes are trimmed

without cracking or discoloration. Nail beds pink. No deformities or ridging noted. Nails well

adhered to nailbed. Scalp is clean with dark brown hair. Hair is evenly distributed, dry, and

clean. No lesions or infestations noted.

HEAD

Head is normocephalic, atraumatic. Anterior and posterior fontanelles not palpable. Skin of face

is clean, dry. No facial deformities noted. No lesions or masses palpated.

NECK
Neck is symmetrical and supple with full range of motion. Trachea is midline. No enlargement,

erythema, or warmth noted to lymph nodes. Lymph nodes are not palpable. No JVD.

EYES

Pupils are equal, round, and reactive to light. Pupils accommodate bilaterally. Eyelids are equal,

no drooping present. Sclera is white bilaterally. Conjunctiva is pink and smooth. No swelling or

erythema. No hemorrhage, discharge, or drainage. Red reflex present bilaterally. Appropriate

fixation and follow of bilateral eyes. No nystagmus. No strabismus. Visual acuity 20/20 (right,

left, and bilateral)

EARS

Tip of ear is equal to the outer canthus of the eye bilaterally. Auricle is round bilaterally. Helix is

firm and lobe is soft. No drainage, lesions, deformities, or tenderness of external ear. Internal

canals are dry with no edema or redness. No cerumen present in bilateral ear canals. Tympanic

membranes are grey and translucent bilaterally. No erythema, fluid, or air bubbles present.

Landmarks visualized bilaterally. Cone of light present bilaterally. Hearing screening passed.

NOSE

Nose is midline. Mucosa is pink, moist, and without edema bilaterally. Nasal septum appears

midline. Nares are patent without erythema. No drainage present. No deformities, tenderness, or

lesions present. No tenderness noted with palpation of frontal and maxillary sinuses.

MOUTH AND THROAT

Lips are pink and moist. Buccal mucosa and gums are pink and moist. Permanent teeth present.

No broken teeth or obvious caries. Tongue is midline, pink, and moist. No sores, lesions, or

swelling noted. Hard and soft palates are intact and pink in color. Uvula is midline. Tonsils are

1+ bilaterally.
CHEST/LUNGS

Chest is symmetrical. Chest expansion is equal bilaterally with regular rate. 18 respirations per

minute. No use of accessary muscles noted. Anterior and posterior lung sounds clear bilaterally

upon auscultation. No wheezing, crackles, or rubs noted.

BREASTS

Breasts are symmetrical and small in size. Breast exam deferred by preceptor. No enlargement,

erythema, or redness of axillary, supraclavicular, or infraclavicular lymph nodes.

HEART/PERIPHERAL VASCULAR

S1 and S2 noted. Heart rate of 73 beats per minute. Regular rhythm noted. No murmurs, gallops,

or rubs noted at the five cardiac points of auscultation. PMI is palpable at the left midclavicular

line at the 5th intercostal space. Capillary refill < 2 seconds. Brachial and femoral pulse regular,

2+. No cyanosis or edema present. Extremities are symmetrical in size, warmth, and color

bilaterally.

ABDOMEN

Abdomen is symmetrical and flat. Skin color is fair. No peristalsis, pulsations, or increased

venous patterns visualized. Active bowel sounds auscultated in all four quadrants. Umbilicus is

inverted. No umbilical hernia noted. Abdomen is soft to palpation. No masses or organomegaly

palpated. Inguinal lymph nodes not palpable.

FEMALE GENITALIA / TANNER STAGE

Exam deferred by preceptor. This should be completed during a well child examination.

MUSCULOSKELETAL
Moving all extremities spontaneously. Joints symmetrical. No edema, erythema, or crepitus

noted. Full range of motion of all joints without difficulty. No scoliosis noted. Equal muscle tone

bilaterally. No atropy or hypertrophy noted.

NEUROLOGIC

Patient is alert and oriented x4. Responds to questions appropriately. Smiles and interacts with

mother and provider appropriately for situation. No weakness noted. No involuntary movements.

ASSESSMENT:

DIAGNOSIS

ICD Codes:

Z00.129 - Encounter for routine child health exam without abnormal findings

PLAN:

Well child exam without any abnormalities.

Recommendations to incorporate more fruits and vegetables were given (AAP, 2017). She was

instructed to limit sugary beverages such as soda, sweet tea, and juice and increase her water

intake (AAP, 2017) . Recommendations to limit screen time and increase physical activity to 1

hour each day was discussed (AAP, 2017). Anticipatory guidance regarding making healthy

behavior choices, violence and injuries, as well as dealing with feelings and coping with stress

was reviewed (AAP, 2017).

Follow up in 1 year for her 18-year-old well child examination (Burns et al, 2017).

Labs:
None

CPT Codes:

99394 - Periodic comprehensive preventive medicine E&M with history and exam, New Pt; 12-

17 year old

99173 – Screening test of visual acuity quantitative, bilateral

92551 – Screening test, pure tone, air only

 References

American Academy of Pediatrics (AAP). (2017). Bright futures. (4th edition).

American Academy of Pediatrics (AAP). (2019). Coding for Pediatric Preventative Care.

Retrieved from https://www.aap.org/en-us/Documents/coding_preventive_care.pdf

Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C., Garzon, D. (2017). Pediatric Primary Care

(6th Edition). Elsevier.

Centers for Disease Control and Prevention. (2018). BMI Percentile Calculator for Child and

Teen: Results. Retrieved from

https://www.cdc.gov/healthyweight/bmi/result.html?&method=english&gender=f&age_y

=17&age_m=0&hinches=65&twp=128

Medscape. (n.d.) CDC Height for Age Percentiles for Girls (2-20 years). Retrieved from

https://reference.medscape.com/calculator/height-age-percentile-girls

Medscape. (n.d.). CDC Weight for Age Percentiles for Girls (2-20 years). Retrieved from

https://reference.medscape.com/calculator/weight-age-percentile-girls