Lucas is a 4-year-old male with 2.5 years of progressive concerns about
language and social development. He has severe expressive language
delay give me the same picture with a kid of 4 years old — WEEK 10
FOR WALDEN UNIVERSITY LOCATION :OUTPATIENT CLINIC WITH X-RAY,
ECG, AND LABORATORY CAPABILITIES FULL CASE STUDY WITH A SOAP
NOTE
LUCAS CHEN, 4M
Chief Complaint: "He's not talking like other kids his age"
,HISTORY OF PRESENT ILLNESS (HPI)
Source & Context:
• Informants: Both parents present (mother primary historian),
reliable
• Setting: 4-year well-child visit in pediatric office
• Timing of Concerns: Approximately 2-2.5 years duration
OLDCARTS Analysis:
O - Onset: Gradual recognition starting around 18 months when
language milestones not met. Parents note increasing concern over past
year as peers advanced in speech.
L - Location/Context: Affects multiple developmental domains:
• Communication: Expressive and receptive language
• Social Interaction: Peer and adult relationships
• Behavior: Play patterns, routines, interests
D - Duration: Concerns present for ~2.5 years, progressively more
noticeable.
C - Characteristics:
• Language Development (Core Concern):
o Expressive: First words at 15 months ("mama," "dada").
Current vocabulary ~50 words (mostly nouns). No phrase
speech - doesn't combine words. Uses single words to label
but not communicate needs. Rarely uses pronouns.
, o Receptive: Follows simple 1-step commands ("get shoes").
Difficulty with complex or abstract language.
o Pragmatics: Doesn't initiate conversation. Doesn't share
interests. Limited back-and-forth interaction.
• Social Development:
o Peer Interaction: Parallel play only. Avoids group activities
at preschool. Doesn't seek out other children.
o Adult Interaction: Prefers parents but doesn't seek comfort
when hurt. Limited joint attention.
o Eye Contact: Fleeting, inconsistent. Parents report "seems
to look through us."
o Emotional Reciprocity: Limited response to others'
emotions.
• Behavioral Patterns:
o Repetitive Behaviors: Lines up toys meticulously, spins
wheels on cars, hand flapping when excited.
o Restricted Interests: Intense focus on trains - watches train
videos repeatedly, only plays with train toys.
o Routine Rigidity: Becomes distressed with changes in
schedule, route to school, or meal presentation.
o Sensory Sensitivities: Covers ears with loud noises
(vacuum, blender). Picky eater - limited to 10 foods, specific
textures.
A - Aggravating/Alleviating Factors:
• Aggravated by: Changes in routine, social demands, loud noises,
unexpected transitions.
• Alleviated by: Predictable routines, solitary play with trains,
watching train videos.
R - Radiation/Pattern: Affects all social and communicative contexts
(home, preschool, community).
language and social development. He has severe expressive language
delay give me the same picture with a kid of 4 years old — WEEK 10
FOR WALDEN UNIVERSITY LOCATION :OUTPATIENT CLINIC WITH X-RAY,
ECG, AND LABORATORY CAPABILITIES FULL CASE STUDY WITH A SOAP
NOTE
LUCAS CHEN, 4M
Chief Complaint: "He's not talking like other kids his age"
,HISTORY OF PRESENT ILLNESS (HPI)
Source & Context:
• Informants: Both parents present (mother primary historian),
reliable
• Setting: 4-year well-child visit in pediatric office
• Timing of Concerns: Approximately 2-2.5 years duration
OLDCARTS Analysis:
O - Onset: Gradual recognition starting around 18 months when
language milestones not met. Parents note increasing concern over past
year as peers advanced in speech.
L - Location/Context: Affects multiple developmental domains:
• Communication: Expressive and receptive language
• Social Interaction: Peer and adult relationships
• Behavior: Play patterns, routines, interests
D - Duration: Concerns present for ~2.5 years, progressively more
noticeable.
C - Characteristics:
• Language Development (Core Concern):
o Expressive: First words at 15 months ("mama," "dada").
Current vocabulary ~50 words (mostly nouns). No phrase
speech - doesn't combine words. Uses single words to label
but not communicate needs. Rarely uses pronouns.
, o Receptive: Follows simple 1-step commands ("get shoes").
Difficulty with complex or abstract language.
o Pragmatics: Doesn't initiate conversation. Doesn't share
interests. Limited back-and-forth interaction.
• Social Development:
o Peer Interaction: Parallel play only. Avoids group activities
at preschool. Doesn't seek out other children.
o Adult Interaction: Prefers parents but doesn't seek comfort
when hurt. Limited joint attention.
o Eye Contact: Fleeting, inconsistent. Parents report "seems
to look through us."
o Emotional Reciprocity: Limited response to others'
emotions.
• Behavioral Patterns:
o Repetitive Behaviors: Lines up toys meticulously, spins
wheels on cars, hand flapping when excited.
o Restricted Interests: Intense focus on trains - watches train
videos repeatedly, only plays with train toys.
o Routine Rigidity: Becomes distressed with changes in
schedule, route to school, or meal presentation.
o Sensory Sensitivities: Covers ears with loud noises
(vacuum, blender). Picky eater - limited to 10 foods, specific
textures.
A - Aggravating/Alleviating Factors:
• Aggravated by: Changes in routine, social demands, loud noises,
unexpected transitions.
• Alleviated by: Predictable routines, solitary play with trains,
watching train videos.
R - Radiation/Pattern: Affects all social and communicative contexts
(home, preschool, community).
