Pediatric
Soap Note # 3: Main Diagnosis: Urticaria (ICD10 L50.9) 2
Soap Note # 3: Main Diagnosis: Urticaria (ICD10 L50.9):
PATIENT INFORMATION
Name: CAL
Age: 15-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: NKA & NKDA. Denies latex allergy
Medication Intolerances: None
Food Intolerances: None.
Current Medications: None
PMH: Unremarkable.
Immunizations:
Influenza November/2020.
Tdap dose Abril/2019.
HPV Completed with 2 doses 9 years ago.
Preventive Care: 6 months ago, within normal limits.
Hospitalizations/Surgeries. None.
Family History: Unremarkable
Chronic Illnesses/Major traumas. None
Social History: Lives with his parents. Patient is currently studying. The patient lives in a family house with his parents, who are kept active and both help the patient financial support.
Toxic habits. No Smoker.
Not use alcohol. Not use illicit drug. No Drink coffee.
Sexual Orientation: Heterosexual. Refers no sexual relations.
Anticonception in use. None.
Nutrition History: Maintains a balanced diet but he likes vegetable and meat. Practice physical exercise frequently at gym.
Prenatal background.
The patient is the only child, from a mother who pregnant at 30 years of age after a stable and functional marriage with the patient’s father, who has the following obstetric history: G1T1P0A0 L1. During the prenatal period she performed at least monthly follow-ups of the pregnancy in her OB consultation, there being no prenatal complications during this period.
Perinatal history.
Patient from a hospital delivery, physiological, without complications at 38.5 weeks gestation. Apgar 9/9
Postnatal Background.
Postnatal period without complications with clinical psychological evolution within normal limits.
Parent’s Current perception of Health: Excellent Good Fair Poor
Good.
Parent’ Social history: _X_ Married __Widowed __Single __ Divorced __Cohabitating Partner
Lives: _X__ Home ___Alone ___ Family ___Caretaker __ ACLF ___ SNF ___
Other: Smoke _None___
ETOH _None________
Recreational Drug Use _None.
Description of milestones according to developmental age.
Psychomotor development (fine and thick), within normal limits during different stages of childhood.
Language with normal development during the different stages of childhood.
Advanced school learning according to school report cards.
Adaptive social development during all stages of his childhood passed within normal limits, without psychological complications. Currently, he maintains a friendly relationship with his classmates without abnormal details to point out.
Food pattern.
He had an exclusive breastfeeding up to 6 months, with development of an adequate level of acceptance and food tolerance during the different stages of childhood.
Teeth development.
Within the limits of normality. Visit the Dentist once a year. He has received caries treatment 6 month ago. Make brushing his teeth after the three main meals.
Subjective Data:
Chief Complaint: “I have been having hives and itching in all my body”
Symptom analysis/HPI:
Patient is a 15 years old, alert and aware, male and Hispanic white, who is visiting the Angel E Rico office and refers skin lesions for the last two weeks. The patient states, “I have been having hives and itching in all my body” and describes that skin lesions appear and disappear spontaneously, and they don’t last more than 2 days with different size and shape. Denies pain (0/10 no pain scale). Denies Shortness of breath. He refers is not taking any medications. His family history is unremarkable. The patient has no history of being hospitalized. No surgical history. Patient never received blood transfusion.
Review of Systems (ROS)
CONSTITUTIONAL. Not Fever. Denies weakness, nighttime sweats. And weight loss and loss of appetite.
NEUROLOGIC: Denies paralysis, tingling, numbness. Denies syncope, seizures, changes in LOC. And photophobia.
HEENT:
Head: Denies any head injury or change in LOC. Denies headache.
Ears: Denies Ear pain, hearing loss, ringing in ears. Denies drainage.
Nose/ Mouth/Throat: Denies sinus problems. Denies dysphagia. Denies problems swallowing, nose bleeds or discharge.
Eyes. Denies secretions. Denies any changes in vision, diplopia, or blurred vision.
RESPIRATORY: Denies cough. Denies shortness of breath. Denies Hemoptysis.
CARDIOVASCULAR: Denies cardiovascular issue and chest pain. No edema. Heart rate feeling within normal limits. No orthopnea or paroxysmal nocturnal dyspnea, chest pain.And orthopnea or paroxysmal nocturnal dyspnea.
