Soap Note
Patient: A 12-year-old patient visiting the physician for well-child examination.
Source and Reliability: Mother and father, both reliable sources.
Subjective (S):
Patient Case, Age and Clinical Setting: 12 years patient visiting a physician.
Chief Complaint: Few minor illnesses over the past 2 years.
HPI: The patient last visited the physician for a well-child examination 2 years ago. He has a few minor illnesses since then. He is currently in the puberty stage of development.
Past Medical History: Few minor illnesses.
Family History: None
Social History: Patient lives with his mother and father.
Risk Factors: Sexual maturation, pubertal growth spurt, and abnormal pubertal development.
ROS: Premature adrenarche.
Objective (O):
VS: BP - 115/70, Temp - 98, weight - 80 pounds, height – 59 inches, HR – 90.
Physical Exam:
· The patient is alert but does not fully understand changes in his body.
·...
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