soap note|2025

Present Concerns/CC:

“He hurt his right arm.”

Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.

8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.

None.

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Updated

Father alive and well, mother alive and well.

He lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.

Denies, headache, chills, myalgia.

Denies chest pain/discomfort, heart problems

Denies rash or lesions.

Denies cough, difficulty breathing, wheezing.

Denies discharge from eye, redness, or pain

Denies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.

Denies pain or discharge

Denies dysuria or changes in urinary pattern.

Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing

Reports injury and pain to left arm

Denies pain or tenderness

Denies loss of consciousness, dizziness, headache, or alteration in mental status

Denies weight loss, activity intolerance, heat or cold intolerance

Denies depression, anxiety, or suicidal ideation

BMI: 18.74

Sp02

No acute distress, well-developed, well nourished, alert.

Skin pink, warm, and dry, no rashes or lesions noted.

Head normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.

S1S2 audible. Regular rate and rhythm. No murmurs.

Lungs clear, good air exchange, no wheezes or rales

Abdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly

Deferred

Bladder is non-distended; no CVA tenderness, external and internal genitalia not examined.

Limited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.

Alert, moves all extremities spontaneously

Age appropriate development.

Right wrist x-ray – closed fracture at distal radius

For adolescents (HEADSSSVG Assessment)

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-ray

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Limited ROM following injury or trauma to the arm suggest possible fracture.

2. Other specified sprain of right wrist, initial encounter – S63.591A

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain.

3. Dislocation of right wrist – M24.331

· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM

· Pertinent negatives – no obvious deformity, no swelling

· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation.

·

· Primary diagnoses: Closed fracture of distal end of right radius – S69.91XA

PLAN including education

· Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)

· Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note provided

· Administer Tylenol or Motrin every 4-6 hours as needed for pain.

· Follow-up with Orthopedics, copy of x-ray CD provided

References

Arora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.3928/00904481-20140417-12