SOAP Note – Wellness of Teenager

SOAP Note – Wellness of Teenager

ID: AW, DOB 1/1/2008, Age 16 Gender: Male Race:  Hispanic.

He presents to the clinic accompanied by his mother. Both are reliable historians. They are also cooperative and respond appropriately to the interview questions asked.

Subjective:

CC: “I have come for my routine wellness check-up.”

HPI: A.W. is a 16-year-old male presenting for his routine wellness check-up accompanied by his mother. His previous check-up a year ago was negative for any physical or psychiatric illnesses. He is currently in his tenth grade and doing well in his studies. His mother reports that AW is doing well at home except for a “few teen problems.” She adds that AW has been hanging around a group of “crooks” lately and does not want to spend much time with the family. He also sneaks outside the house occasionally to party with his friends. The mother also notes that AW has become rebellious to the instructions and warnings given to him by his parents. He also likes bringing his girlfriend to the house despite opposition from his father.

Past Medical History:

• Medical problem list

The patient has never had any medical problems.

• Surgical:

– AW has no history of surgeries

Preventive Care:

-AW has been presenting for annual medical check-ups every year for the past seven years. He had a dental check-up in February.

Allergies:

– No known allergies.

Medications:

-AW is not on any medications.

Immunizations:

– The patient is up to date with all his childhood vaccines. He recently received his booster shot of the meningococcal disease vaccine ( MenACWY). He has also received all of his Covid-19 vaccines, including a booster shot for the Pfizer vaccine. He has also received his annual influenza vaccine.

Social History:

• Chemical history: The patient had his first instance of smoking last month. His mother affirmed that she found a used e-cigarette in the patient’s bag last week. He denies having a history of using alcohol or any other illicit substances.
• Sexual history and contraception/protection: The patient is a 16-year-old teenager in his tenth grade. He has a girlfriend but has never indulged in any form of sexual intercourse. He, however, admits that he was planning to have sexual intercourse with his girlfriend before the end of the summer.

Other:

The patient is the last born in a family of five. His older siblings are in college. He relates well with his family members. His mother, however, reports that he no longer joins the family in church and occasionally skips the family gatherings. His family lives in a rented three-bedroom apartment. The family eats three meals a day and has a balanced diet. The patient expresses his love for fast food. The patient sleeps at least 8 hours per day. He denies having any difficulty inducing or maintaining sleep.

• Safety:

– The family does not own any guns. They live in a safe neighborhood and have never experienced any extreme incidence of violence. The patient practices safety behaviors such as wearing protective equipment, such as helmets and gloves when conducting outdoor activities. He also wears a safety belt whenever he is in a car.

• Family History:

The patient has a negative history of any chronic illness or mental health disorders.

Review of Systems

Constitutional: AW denies weight loss, weakness, fatigue, fever, or chills.

Eyes: The patient denies visual loss, blurred vision, or double vision. He also denies eye discharge or eye itchiness.

Ears/Nose/Mouth/Throat: AW denies experiencing earache, tinnitus, hearing loss, or ear discharge, tinnitus, ear discharge, or hearing loss. He also denies nasal congestion, discharge, gum bleeding or swelling, sore throat, difficulty swallowing, or hoarseness of voice.

He also denies nasal discharge, congestion, gum bleeding, or gum swelling. The patient also denies having a sore throat or difficulty swallowing.

Cardiovascular: AW denies having irregular heart rhythms, palpitations, or swelling in the extremities.

Pulmonary: The patient denies chest pains, unusual cough, wheezing, shortness of breath, or difficulty breathing.

Gastrointestinal: AW denies changes in his bowel movement or abdominal pain. He also denies flatus or abdominal distension.

Genitourinary: Denies urinary frequency, dysuria, urinary hesitancy, urinary color change, hematuria, or nocturia. He also denies penile discharge.

Musculoskeletal: Denies muscle pain, muscle weakness, or muscle stiffness. He also denies swelling, tenderness, bruising, and erythema on his joints. The patient also denies having any joint deformity or decreased range of motion in all his joints.  He has a negative family history of musculoskeletal pathology.

Integumentary: The patient denies experiencing any skin itchiness or rashes. He also denies having any skin lesions, scars, swelling, nodules, skin color inconsistencies, or abnormal thickening. He has a negative history of pressure injuries, lymphedema, or eczema.

Neurological: The patient denies weakness, dizziness, or recent syncope.

Psychiatric: The patient denies depression, anxiety, suicidal ideation, or tendencies.

Endocrine: Denies weight loss or weight gain or heat and cold intolerance.

Hematologic/Lymphatic: Denies any ease of bruising, anemia, or excessive bleeding. He also denies splenomegaly or lymph node swelling.

Allergic/Immunologic: The patient has no known allergies.

Objective

Vital Signs: HR: 69 BP: 119/71 Temp: 97.7 F RR: 17 SpO2: 100% Height: 5’8 Weight: 165.12 lbs. BMI: 23.6

Labs, radiology, or other pertinent studies:

Complete Blood Count for AW.: This test was done as part of the routine check-up to measure different parts of the blood. The test can give insights into potential inflammatory processes, anemia, and infections that would not have been picked up during subjective assessment and physical examination.

Hematology	Result	Normal range
Red cell count	5.5 x 1012/L	4.5–5.7
White cell count	12 x 109/L	4.0–10.0
Hemoglobin	160 g/L	133–167
Hematocrit	0.50	0.35–0.53
MCV	80 fL	77–98
MCH	27 pg	26–33
MCHC	332 g/L	330–370
RDW	10.5%	10.3–15.3

Physical Exam

General Survey: The patient cooperates with the caregivers and responds well to the interview questions asked. There are no signs of wasting, weight loss, fatigue, or chills.

HEENT: The head is well-rounded, atraumatic, and normocephalic. No sign of head swelling, masses, or nodules. The hair is well distributed on the scalp. There are no signs of unusual hair thickening or alopecia on the scalp. No signs of discomfort or pain on palpation of the head. The eyes are symmetrical. No sign of eye discharge, drooping, puffiness, or eyelid retraction. PERLLA is present bilaterally. The visual acuity is 20/20.  There is no sign of scleral redness or eye cataracts. The ears are symmetrical. No sign of ear discharge, bulging, or thickening in the ear septum. The ear canal is lined with hair.  The tymapci menrane is clear. Both the whisper test and the friction rub tests were negative. The nose is symmetrical. No sign of nasal discharge, nasal swelling, polyps, or any nasal malformation. The patient could breathe through each nostril. The patient’s sense of smell was intact. The lips were smooth and symmetrical. No sign of lip swelling, dryness, cracking, or discoloration. There was also no sign of gum swelling or bleeding. The tongue is moist and pink in coloration. No sign of tongue ulcerations or discoloration. There was also no sign of uvular deviation.

Neck: The neck is symmetrical. There were no signs of scars, rashes, or nodules on the neck.  No signs of pain or discomfort on extending, rotating, and bending the neck.  The trachea is midline on the neck. No visible extended veins on the neck. There were also no palpable lymph nodes on the necks. The shoulder shrug test was negative.

CVS: The heart rate is regular and rhythmic. No murmurs, pericardial friction rub, or gallop sounds were heard on auscultation. The S1 and S2 sounds were also heard. No signs of jaundice, peripheral edema, or cyanosis.

Chest/Thorax: The chest wall is symmetrical. No sign of any chest wall defects or deformity. No sign of labored breathing or use of accessory muscle of inspiration. No wheezing, rhonchi, or respiratory crackles sounds were heard. The apical pulse was heard on auscultation.

Abdominal: The abdomen is well-rounded and symmetrical. No signs of scars rashes, skin color inconsistencies, or lesions on the abdominal wall. Abdominal sounds were heard in all the quadrants. Abdominal bruit sounds were also heard on auscultation of the area over the iliac artery and the aorta. There were no signs of tenderness or abdominal pain on palpation.

Integumentary: No sign of skin lesions, rashes, scars, or skin color inconsistencies. The skin was warm and moist, with an even distribution of hair on bilateral examination of the arms and legs. No sign of skin pallor or cyanosis. The skin tugor was good. The limb circumference was even bilaterally, with no sign of edema. The capillary refill time was 2 seconds on the lower and upper extremities.

Neurological Examination

Cognition: The patient is alert and cooperative. He is responsive and answers the questions asked appropriately. He can name objects, follow written commands, and follow three-step contralateral localization commands.

Orientation: The patient is aware of his surroundings. He is dressed appropriately for the occasion and weather of the day. He verbalizes why he is presenting to the clinic.

Speech: The patient has a normal speech.  His tone is also consistent. There was no sign of slurred speech or inappropriate shouting. His speech is also logical and goal-directed.

Memory and reasoning: AW has an intact memory, as demonstrated by his ability to recall current and past events. His reasoning is also logical.

Cerebellum

Balance: AW has a normal gait. He was able to make five consecutive steps, walking on her toes. He was also able to make ten consecutive steps when walking in a heel-to-toe manner in a straight line. AW was also able to maintain an upright position after closing his eyes for one minute.

Sensory: AW could ascertain the position of his joints with his eyes closed. He could also discern two nearby objects placed at distinct positions on his skin. The patient could also distinguish cotton rub, pinpricks, and vibrations on his skin.

Motor System: AW could resist pressure applied bilaterally to his shoulders. He was also able to make jump movements and squats.

Assessment

Differential Diagnoses

1. Encounter for routine child health examination with abnormal findings (ICD 10 Z00.121): Encounter with routine child examination with abnormal findings is a WHO classification under child wellness denoting the presence of one or more factors influencing the health of a child. Several factors can negatively influence the health and wellness of children and adolescents. Environmental factors such as exposure to toxins, pollutants, and infectious agents, social factors such as peer interactions, and access to high-quality healthcare and education can all influence the health and wellness of a child (Tabrizi et al., 2024). In the case presented, collaborative history from the mother revealed that the teen has been hanging out with people her mother considers as crooks. Likewise, the patient tended to sneak out with his peers to party. Further assessment showed that the child had developed a rebellious attitude and was not conforming to the instructions given to him. These findings reveal anomalies in the social wellness of the child that may predispose him to harm.
2. Sex counseling ICD 10 Code Z70.8: Sex counseling is integral to teen reproductive health. Adolescents are likely to face diverse social and health challenges. Vasilenko, (2022) notes that adolescents are more likely to be sexually active. Likewise, they are more likely to indulge in sexual activities due to peer influence and curiosity that characterizes adolescence. Mudhune et al. (2024) add that adolescents who have sexual intercourse at early ages are more likely to have multiple sexual partners, contract sexually transmitted infections, and use condoms less frequently. Poor knowledge of sexual health has also been associated with unwanted pregnancies, unsafe abortions, and early marriages. It is for these reasons that sex counseling is important. In the case presented, the patient is an adolescent. He also admits to having a girlfriend. Poor knowledge of contraceptives and healthy sexual behaviors may predispose the patients to sexually transmitted infections, and other risks associated with poor sexual behaviors.
3. Teen smoking ICD 10 Code F17.210: Teen smoking is a major health concern among teenagers and young adults. According to the CDC, tobacco use is started and established during adolescence. Additionally, 90 % of daily smokers had their first attempts at smoking before their 18th birthday. E-cigarettes are the most commonly used form of tobacco among teens (Mejia et al., 2023). Regardless of the form, smoking remains harmful to the physical wellness of adolescents. It predisposes them to diverse cardiovascular illnesses such as hypertension and heart disease and is a leading modifiable risk factor for several cancers (Afolalu et al., 2021). In the case presented, the patient had had his first attempt at smoking. Likewise, collaborative history from the mother revealed a used e-cigarette in the patient’s bag. This demonstrated cigarette use.  Healthy People 2030 advocates for the reduction in teen smoking. It proposes teen education on the harmful effects of smoking as a measure to curtail increases in the prevalence of teen smoking. It is thus important that the patient is educated on the harmful effects of smoking to lower his likelihood of smoking.

Diagnosis: Encounter for routine child health examination without abnormal findings. Collaborative history, along with the subjective findings revealed several instances of abnormalities in his health and wellness. The negative peer influences around him, his rebellious attitude, and his indulgence in smoking are abnormal findings that predispose the child to various health harms.

Plan

Encounter for routine child health examination with abnormal findings (ICD 10 Z00.121):

Diagnostics:

• STI screening. The CDC recommends screening for heterosexual males in high-prevalence clinical settings such as adolescent clinics (CDC, 2024). STI screening is also recommended for partners planning to start having sexual intercourse. It is important that STI screening be performed on the patient as he meets the criteria set out by the CDC for STI screening among teens.

Treatment:

• Lifestyle modification to eliminate behaviors predisposing the patient to various health harms is necessary. The patients, in this respect, should be advised against interacting with negative peer influences to lower their predisposition to various health harms (CDC, 2024). He should also be advised against negative health behaviors such as smoking, alcohol consumption, and unprotected sexual intercourse. Medications may be necessitated when STI screening turns out positive for a sexually transmitted infection.

Education: 

• The patient should be educated on the significance of routine wellness check-ups in ensuring teen wellness. He should be told that wellness checks allow caregivers to educate teens on diverse aspects of wellness. Wellness checks may also facilitate the detection and treatment of underlying illnesses that could otherwise be devastating to the patient.
• The patient and his parents will be educated on the determinants of health and their role in health and wellness. In this respect, AW’s mother will be advised to take a proactive role in his son’s life. She should encourage him to adopt positive health behaviors while reducing negative behaviors predisposing him to harm (WHO, 2024). She should also be educated on effective parenting strategies, such as open communication and compassion and their significance in establishing meaningful bonds between parents and their children.
• The patients will be educated on social wellness as a determinant of health. He will be advised to choose those he associates with to minimize negative peer influences on his health. Minimizing the time he has with friends who influence him towards drug use may help lower his vulnerability to indulging in negative behaviors. He should also be advised to identify and pursue a hobby, as hobbies can eliminate idleness and subsequent predisposition to indulging in otherwise harmful behaviors.
• The patient should also be educated on the significance of family in enhancing social wellness. As An et al. (2024) report, family is integral to social wellness, as it provides a safety net for the emotional well-being of the family members. The patients should thus be advised to relate well with their family members and minimize isolatory tendencies towards them.
• The patients should also be advised against teen smoking. He should be told that teen smoking is a modifiable risk factor for cardiovascular illnesses, such as hypertension and heart disease, and several cancers. (WHO, 2024). To improve the patient’s compliance on smoking cessation initiatives, he should be educated on the available resources that may help him deal with smoking. These include the CDC and community anti-smoking campaign groups.
• The patient should also be educated on safe sex. He should be told that unprotected sexual intercourse predisposes him to various reproductive health illnesses. These include, sexually transmitted infections such as HIV and chlamydia infections, and unwanted marriages, among others. The patients should be advised on the effective use of condoms, as a contraceptive method (CDC, 2024).

Follow-Up:

• The patient should return for a wellness check after a year. The CDC recommends that teens should present for wellness checks yearly to ensure optimal development (CDC, 2024).

References

Afolalu, E. F., Spies, E., Bacso, A., Clerc, E., Abetz-Webb, L., Gallot, S., & Chrea, C. (2021). Impact of tobacco and/or nicotine products on health and functioning: A scoping review and findings from the preparatory phase of the development of a new self-report measure. Harm Reduction Journal, 18(1). https://doi.org/10.1186/s12954-021-00526-z

An, J., Zhu, X., Shi, Z., & An, J. (2024). A serial mediating effect of perceived family support on psychological well-being. BMC Public Health, 24(1). https://doi.org/10.1186/s12889-024-18476-z

CDC. (2024, March 22). STI screening recommendations. Centers for Disease Control and Prevention. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm

Mejia, M. C., Adele, A., Levine, R. S., Hennekens, C. H., & Kitsantas, P. (2023). Trends in cigarette smoking among United States adolescents. Ochsner Journal, 23(4), 289–295. https://doi.org/10.31486/toj.23.0113

Mudhune, V., Winskell, K., Bednarczyk, R. A., Ondenge, K., Mbeda, C., Kerubo, E., Ndivo, R., Arego, J., Morales, M., Halliburton, B., & Sabben, G. (2024). Sexual behaviour among Kenyan adolescents enrolled in an efficacy trial of a smartphone game to prevent HIV: A cross-sectional analysis of Baseline Data. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 21(1). https://doi.org/10.1080/17290376.2024.2320188

Tabrizi, J. S., Doshmangir, L., Khoshmaram, N., Shakibazadeh, E., Abdolahi, H. M., & Khabiri, R. (2024). Key factors affecting health promoting behaviors among adolescents: A scoping review. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-023-10510-x

Vasilenko, S. A. (2022). Sexual behavior and health from adolescence to adulthood: Illustrative examples of 25 years of research from ADD health. Journal of Adolescent Health, 71(6). https://doi.org/10.1016/j.jadohealth.2022.08.014

WHO. (2024, March 2). Improving the health and Wellbeing of Children and Adolescents: Guidance on scheduled child and adolescent well-care visits. World Health Organization. https://www.who.int/publications/i/item/9789240085336

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Students may use this general SOAP note template or their own.  Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.