NU 6541 WEEK 3 SOAP NOTE| FOLLOW UP EVALUATION

NU 6541 WEEK 3 SOAP NOTE| FOLLOW UP EVALUATION SUBJECTIVE DATA: Chief Complaint (CC): Episodes of altered mental status, follow up from recent hospitalization History of Present Illness (HPI): 12-year-old African American female brought to clinic with mother for follow up evaluation after hospitalization. Two days prior, patient was at school with she became altered and had episodes of jerking movements. Mother states that during these episodes patient did not respond to others and just seemed to stare off. Patient does not remember episodes occurring. Patient had numerous episodes like this during ER evaluation and 2 during hospitalization at local children’s hospital. Mother states that only one has occurred since hospital discharge. Patient has significant health history including autism, depression, asthma and eczema. Patient was discharged and told to follow up with primary pediatrician and schedule appointment for EEG to be done. Mother is still concerned regarding these episodes happening. Mother denies anything like this occurring before. Patient denies pain, or anything that happens before these episodes begin. Mother states that episodes that have been witnessed last several minutes. Patient had GCS of 10 on arrival to ER 2 days prior but was responsive to pain. Mother states that during episodes that child was “floppy” but could move. Patient’s speech is reported to be garbled during these episodes. Denies any recent changes to medications. Mother states that since hospital discharge, she stopped giving patient all medication for fear that it was a medication side effect. Children’s hospital sent admission summary to clinic but did not send discharge summary or current test results. Medications: Advair 2 puffs BID Albuterol inhaler PRN Flonase 1 spray each nostril daily Singulair 5 mg PO at bedtime Paroxetine 30mg PO at bedtime Imipramine 25mg PO PRN- Mother reports that she occasionally takes this is she drinks a lot prior to bed. Last dose was 1 week prior to event occurring. Trazodone PRN Allergies: NKDA Past Medical History (PMH): Autism, Developmental Delay, Anxiety, Depression, Asthma, Eczema, Multiple environmental allergies, & Preterm birth at 32 weeks- weighing 3lbs 12oz. Past Surgical History (PSH): Esophagogatroduodenoscopy for reflux prior to 1 year of age. Sexual/Reproductive History: Denies onset of menarche. Denies any sexual behavior. Personal/Social History: Denies tobacco, alcohol or drug use. Patient is in a special needs class at school. Patient has good appetite, mother states that she is not a picky eater. Immunization History: Immunizations are up to date. Received flu and pneumonia vaccination this past Winter. Significant Family History: Maternal aunt and paternal great uncle have history of seizures. Mother has Rheumatoid arthritis, fibromyalgia, anxiety, GERD, migraines, and hyperlipidemia. Grandparents have history of heart disease, lymphoma, and mitral valve prolapse. Lifestyle: Mother states that their family is Pentecostal. Mother also states that patient’s father does not believe in the patient taking too many medications. Patient lives with mother and siblings. Patient attends a special needs school. Patient has been bullied at school in the past. Home has running water, and electricity. Review of Systems: General: Patient denies any pain. Patient denies any symptoms. She states that she does not feel funny at all. Mother denies any recent changes in appetite or weight. Mother states that she took Imipramine one week prior to these episodes. Mother keeps medication locked up and denies patient taking any extra. HEENT: Patient states that she did have occasional headaches 1-2 weeks prior to event. Denies any glasses or contacts. Denies difficulty hearing or seeing. Denies any drainage or irritation to eyes or ears. Denies loss or smell. Denies difficulty swallowing. Mother states that patient has regular eye and dental exams. Mother states that during episodes that patient will stare off blankly, not responding to staff or family. Mother states that patient’s speech became garbled during one episode. Neck: Denies any tenderness, pain, or swelling. Breasts: Denies pain Respiratory: Denies difficulty breathing, or pain. Cardiovascular/Peripheral Vascular: Denies any swelling in extremities, denies