2-month visit H&P

CC: 2-month-visit

Subjective
* HPI: Patient X.X. is a 2-month-old infant male/female who is here for his/her 2-month checkup. Patient is present here today with his/her mom/dad. Patient is awake, sitting quietly in carseat, no signs of respiratory ditress/awake, being held by mom and crying. 

2-month visit: Has done well over the past month. Alert to sights and sounds. Coos and smiles. Turns to sound. Holds object. Recognizes face. No concerns regarding hearing. No problems with urine or stool. Sleeps on back. Usual sleep pattern. Mom/Dad says that baby is growing and is also able to sleep longer than before, about q3-4 hours at a time. 

Nutrition includes ***nursing every 2-3 hours/--- formula every 2-3 hours***. 
Nutrition includes 6-8 oz / feeding, 4-6 feedings/ 24 hours (94-130 kcal/kg/day). 
Nutrition includes 4-5 oz / feeding, q3-4 6-8 feedings / 24 hours 
(^*Education: * Encouraged mom/dad to increase amount per feeding due to growth percentile.)
Stools: 1-5 yellow, pasty, but formed stools/24 hours 
(Breastfed babies will have more stools than bottle-fed babies)
Void: q1-3 hours/with each feeding and diaper change  

* ROS
-​​Skin: denies rashes or lesions; denies new nevi
-HEENT: Head: denies migraines/headaches; Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing; denies tinnitus or vertigo. Nose/Sinuses: denies nasal congestion, sinus pressure/pain, and epistaxis. Teeth: denies issues
-Neck/Throat: denies pain, lumps, or lymphadenopathy 
-Cardiovascular: denies chest pain, palpitations, or tachycardia. 
-Respiratory: denies cough, congestion, wheezing, or dyspnea
-Gastrointestinal: denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues
-Genitourinary: denies any problems 
-Musculoskeletal: denies joint stiffness, joint pain or swelling
-Integumentary/Breast: denies rash, pain, or masses
-Neurological: denies seizures, sensory loss, headaches, migraines, or lethargy
-Hematologic/Lymphatic: denies bruising, bleeding, and lymphadenopathy generally
-Endocrine: no reported hair loss; skin is warm and dry; no night sweats reported 
-Psychiatric: denies anxiety and depression.


Objective
* Vitals: HR 100-190, RR XX Wt XXlb, Ht XX in, BMI XX index, BP XX, Spo2 98%

* Physical Exam
General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head:  Normocephalic with age appropriate fontanelles.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light.  Red reflex present bilaterally.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.


ASSESSMENT / PLAN

ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS
* Injury prevention and health promotion issues discussed such as no smoking in the house or around the baby, risks of secondhand smoke exposure, and risks of choking and dental caries with feeding baby with a propped bottle. Educated on dangers of co-sleeping.    
* Immunizations given today include DTaP, IPV, Hepatitis B, PCV, Hib & RV. Side effects, risks, and benefits of immunizations discussed. Return to clinic at 4 months of age, or sooner if concerns arise. 

Follow up: 4-month visit 
CC: 2-month-visit

Subjective
* HPI: Patient X.X. is a 2-month-old infant male/female who is here for his/her 2-month checkup. Patient is present here today with his/her mom/dad. Patient is awake, sitting quietly in carseat, no signs of respiratory ditress/awake, being held by mom and crying.

2-month visit: Has done well over the past month. Alert to sights and sounds. Coos and smiles. Turns to sound. Holds object. Recognizes face. No concerns regarding hearing. No problems with urine or stool. Sleeps on back. Usual sleep pattern. Mom/Dad says that baby is growing and is also able to sleep longer than before, about q3-4 hours at a time.

Nutrition includes ***nursing every 2-3 hours/--- formula every 2-3 hours***.
Nutrition includes 6-8 oz / feeding, 4-6 feedings/ 24 hours (94-130 kcal/kg/day).
Nutrition includes 4-5 oz / feeding, q3-4 6-8 feedings / 24 hours
(^*Education: * Encouraged mom/dad to increase amount per feeding due to growth percentile.)
Stools: 1-5 yellow, pasty, but formed stools/24 hours
(Breastfed babies will have more stools than bottle-fed babies)
Void: q1-3 hours/with each feeding and diaper change

* ROS
-​​Skin: denies rashes or lesions; denies new nevi
-HEENT: Head: denies migraines/headaches; Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing; denies tinnitus or vertigo. Nose/Sinuses: denies nasal congestion, sinus pressure/pain, and epistaxis. Teeth: denies issues
-Neck/Throat: denies pain, lumps, or lymphadenopathy
-Cardiovascular: denies chest pain, palpitations, or tachycardia.
-Respiratory: denies cough, congestion, wheezing, or dyspnea
-Gastrointestinal: denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues
-Genitourinary: denies any problems
-Musculoskeletal: denies joint stiffness, joint pain or swelling
-Integumentary/Breast: denies rash, pain, or masses
-Neurological: denies seizures, sensory loss, headaches, migraines, or lethargy
-Hematologic/Lymphatic: denies bruising, bleeding, and lymphadenopathy generally
-Endocrine: no reported hair loss; skin is warm and dry; no night sweats reported
-Psychiatric: denies anxiety and depression.


Objective
* Vitals: HR 100-190, RR XX Wt XXlb, Ht XX in, BMI XX index, BP XX, Spo2 98%

* Physical Exam
General: Child appears age appropriate. Vitals noted and stable.
Skin: Normal turgor and without lesions.
Head: Normocephalic with age appropriate fontanelles.
Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally.
ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally.
Lymph Nodes: No significant lymphadenopathy.
Thyroid: No thyromegaly; trachea midline without masses.
Breasts: Without lesions or drainage.
Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds.
Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions.
Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention.
Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia.
Spine: Straight with no lesions.
Joints: Full range of motion about all joints.
Extremities: Digits and nails are normal
Gait: Normal and appropriate gait for age.
Mental Status: Alert, oriented, in no distress. Appropriate for age.
Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.


ASSESSMENT / PLAN

ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS
* Injury prevention and health promotion issues discussed such as no smoking in the house or around the baby, risks of secondhand smoke exposure, and risks of choking and dental caries with feeding baby with a propped bottle. Educated on dangers of co-sleeping.
* Immunizations given today include DTaP, IPV, Hepatitis B, PCV, Hib & RV. Side effects, risks, and benefits of immunizations discussed. Return to clinic at 4 months of age, or sooner if concerns arise.

Follow up: 4-month visit

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 641 boilerplate words
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: