2-year visit, Peds, Full SOAP

CC: [text name="variable_1" default="2-year wellness"]
Subjective
HPI: [textarea name="variable_2" default="Patient -initials- is a -age- -ethnicity- -male/female- who who is here for his/her 2-year wellness visit. Patient is an -established patient with the clinic--new patient to the clinic-. Patient is here today with -his/her- mom /dad /grandma /grandpa /who has written consent from legal guardian."]
[textarea name="variable_3" default="Patient’s demeanor appropriate for his/her age, he/she makes appropriate eye contact, and is walking around the examination room exploring, and smiling."]
[textarea name="variable_4" default="Patient is fussy/irritable/ being held by mom/dad crying / sitting quietly in car seat / crying in car seat"]
2-year visit: [textarea name="variable_5" default="Mom reports patient is doing well, talking and walking more and has lots of energy. She says she provides him/her with different toys that he/she loves playing with that have different colors, sounds, and textures. He/She is also doing well with potty training so far. Sleeps well through the night. ***** Mom reports patient is doing well / toilet training / increasingly indepedent and active / temper tantrums"]

Nutrition: [textarea name="variable_10" default="a variety of foods from the table, with new foods being spaced apart w/ enough time to observe for allergies"]
Voids: [text name="variable_11" default="8-10 x/day"]
Stools: [text name="variable_12" default="soft, formed, 2/day"]
Drug Allergies: [text name="variable_13" default="NKDA."]
Medical History: [text name="variable_14" default="None."]

* ROS
-Skin: [textarea name="variable_15" default="denies rashes or lesions"]
-ENT:[textarea name="variable_16" default="Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing, tinnitus, vertigo, ear pain or discharge; Nose/Sinuses: denies nasal congestion, sneezing, sinus pressure/pain, and epistaxis. Teeth: denies issues. *****c/o eye dryness / discharge / itchiness / c/o ear drainage / pain / tenderness / tinnitus / vertigo"]
-Neck/Throat:[textarea name="variable_17" default="denies pain, lumps *****admits to sore throat / difficulty swallowing"]
-Cardiovascular: [textarea name="variable_18" default="denies chest pain, palpitations, or tachycardia. *****has cardiac history of"]
-Respiratory: [textarea name="variable_19" default="denies cough, congestion, wheezing, or dyspnea *****c/o cough, congestion, wheezing, dyspnea"]
-Gastrointestinal: [textarea name="variable_20" default="denies gassiness or constipation; reports regular voids and stools w/no issues, denies vomiting, diarrhea, constipation *****c/o nausea, vomiting, diarrhea, reflux"]
-Genitourinary: [textarea name="variable_21" default="denies any issues"]
-Musculoskeeltal: [textarea name="variable_22" default="denies abnormalities or concerns in baby’s movements or gait"]
-Neuro: [textarea name="variable_23" default="denies abnormal, jerky movements; no concerns"]Objective
* Vitals: HR [text name="variable_24" default=" "], RR [text name="variable_25" default=" "], Wt [text name="variable_26" default=" "], Ht [text name="variable_27" default=" ( % percentile)"],
Head Circ [text name="variable_28" default=" ( % percentile)"]* Physical Exam
General: [textarea name="variable_29" default="Child appears age appropriate. Vitals noted and stable. Well developed. Well nourished. Well groomed. No signs of respiratory distress *****Child is ill-appearing / appears fatigued."]
-Skin: [textarea name="variable_30" default="no signs of rashes or lesions"]
HEENT: Head: [textarea name="variable_31" default="normocephalic; no lesions, rashes, or infestations"]
Eyes: [textarea name="variable_32" default="Conjunctivae noninjected, sclerae anicteric, lids without ptosis, edema, erythema, extraocular movements intact, pupils equal, round, and reactive to light *****BILATERAL watery eyes / purulent discharge / mucopurulent discharge / UNILATERAL / LEFT / RIGHT / watery eyes / purulent discharge / mucopurulent discharge"]
Ears: BOTH EARS: [textarea name="variable_33" default="TMs w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TMs dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
RIGHT:[textarea name="variable_34" default="TM w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TM dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
LEFT:[textarea name="variable_35" default="TM w/out effusion, mobile, non-bulging, gray, sharp landmarks. ***** TM dull w/ effusion, mobile, non-bulging, gray, sharp landmarks / with air-fluid levels behind it / tympanic membrane is perforated / tympanic membrane is erythematous, bulging and non-mobile / tympanic membrane is erythematous, but is non-bulging and is mobile / ear drainage noted on exam / impacted cerumen"]
Nose/Sinuses: [textarea name="variable_36" default="nares patent, no erythema, no drainage *****clear nasal drainage bilaterally / mucopurulent rhinorrhea bilaterally / dried mucus bilaterally"]
Mouth/Throat: [textarea name="variable_37" default="Non-inflamed bilaterally, uvula midline, no petechiae or exudate, Tonsils 1+; Teeth: Dentition normal for age, no significant carries noted *****Mild erythema / erythema to anterior arch / erythema to pharynx / Cobblestoning / Petechiae noted to pharynx / petechiae / exudate / tonsils surgically removed"]
Neck: [textarea name="variable_38" default="Supple. No significant lymphadenopathy."]
Heart: [textarea name="variable_39" default="Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs; no significant cardiac history "]
Lungs: [textarea name="variable_40" default="Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions; dry cough noted during exam"]
Abdomen: [textarea name="variable_41" default="Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
Genitalia: [textarea name="variable_42" default="Normal male appearnce. Testes descended bilaterally, no signs of swelling or herniation / Normal female appearance. No signs of labial adhesions"]
Rectum: [textarea name="variable_43" default="no swelling or lesions"]
Musculoskeletal: [textarea name="variable_44" default="ROM to all extremities/patient’s expected normal; no joint deformities or swelling"]
NEUROLOGIC: [textarea name="variable_45" default="Normal tone. Cranial nerves grossly intact. Motor/sensory grossly normal."]
SPINE: [textarea name="variable_46" default="Normal curvature with no defects"]*LABS: [text name="variable_47" default=" "][checklist name="variable_48" value="None."]
*DIAGNOSTICS: [text name="variable_49" default=" "][checklist name="variable_50" value="None."]PREVENTATIVE HEALTH
Immunizations: [textarea name="variable_51" value="UTD / DTAP/IPV/HPEB/PCV/HIB/RV/HEPA/MMR/VARICELLA"]
ASSESSMENT/PLAN
[textarea name="variable_52" default="Z00.129 - ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS * Injury prevention and health promotion issues discussed. Discussed well-visit appointment schedule and immunization schedule. * Provided education on various topics of safety including using rear-facing car seats in back seat, never in front seat of vehicle with air bag, keep home/vehicle smoke free, never shake or hit baby/toddler, and avoid illness exposure. Discussed coping strategies and appropriate discipline measures w/ temper tantrums."]
[textarea name="variable_53" default="Z23 - ENCOUNTER FOR IMMUNIZATION * Vaccination schedule reviewed. *****No immunizations given today / Immunizations given today include HepB/IPV/MMR/HEPA/RV/INFLUENZA"]
Follow-up: [text name="variable_54" default="30-months-old"]