(SOAP NOTE) NR511 Jo AGE 5 FEMALE (CC Difficult to get children to bed at night and stay in bed)

(SOAP NOTE) NR511 Jo AGE 5 FEMALE (CC Difficult to get children to bed at night and stay in bed) Jo AGE 5 YEARS FEMALE Subjective Chief complaint: difficult to get the children to go to bed at night and stay in bed History of present illness (HPI): The mother denies any recent illnesses in either child and reports they are here for their check-up. She does report that since moving in with her parents recently, it has been difficult to get the children to go to bed at night and stay in bed and expresses extreme frustration with this. Jo has been getting up to play in the room at night and She reports that they are eating three meals per day and two snacks, one at bedtime and one in the afternoon between lunch and dinner. Riley is still taking infant formula. Mother brushes their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home. She also verbalizes extreme concern of their impending loss of health insurance. Past Medical History/Birth history: Full-term gestation, born cesarean section, weight. 7 pounds 4 ounces. There were no complications in pregnancy, but the mother did smoke 1 pack-per-day throughout pregnancy. There were no hospitalizations—NKDA Nutrition: The daily medication was chewable children’s multivitamin with iron. They eat three meals and two snacks. There is a great deal of juice, soda, and processed or quick foods given in the house. Immunizations: Birth Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A Family History: They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving. Other family members died of old age. She is unaware of paternal familial health history. Social and environmental history: Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives several hours away where he works. Jo will be starting kindergarten this fall in the community’s elementary school. Cultural history: They are Latin American in descent, the grandparents emigrated from Cuba in the 1970s. Jo and Riley are United States soil. Review of Systems: Neurologic: Frequent morning headaches? Do you have any developmental concerns? Is she hyperactive while at school? Any difficulties paying attention? Irritability of mood swings throughout the day? Head/Eyes/Ears/Nose/Mouth/Throat: Does she have enlarged tonsils? Frequent colds or sore throats? Frequent ear infections? Changes in vision? Changes in hearing? 1 | P a g eIntegumentary: Any rashes, reports of itching, change in pigmentation, excessive moisture or dryness, presence of wounds, presence of invasive devices, alterations in texture, changes in hair growth, texture or loss, nail changes, tenderness, no swelling Cardiovascular: cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations Respiratory: Does she mouth breath or have trouble breathing through the nose? Asthma? Genitourinary: Any urgency, frequency of urination at night? Any blood in the urine? Endocrine: Have you noticed excessive weight gain? Or failure to gain weight? Any increase in hunger, thirst, urination or problems with hot or cold environments? Gastrointestinal: Does she have difficulty swallowing and/or drooling? Have you had any complaints of nausea vomiting or stomach acid reflux? Do any of the following occur: changes in appetite, dysphagia, and indigestion, food intolerances to milk products, abdominal pain, heartburn, denies nausea, denies vomiting, denies hematemesis, no jaundice, or denies constipation? Musculoskeletal: Does she sleep walk? Any muscular disorders? Hematologic: Any prevalent genetic disease? Any bleeding problems in skin; excessive bruising. Exposure to toxins, any blood transfusions. Objective Vital signs: height: 110 centimeters 75th percentile; weight: 29 kilograms, BMI 24.0 (Normal 18.5- 25) BMI percentile is 95% B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, nonlabored, SpO2: 99% General: Cooperative, talkative, appropriate; HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; fundoscopic exam unremarkable; vision by Snellen exam 20/40 in each eye, 20/30 together; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bilateral Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal; GU – labia majora and minora intact, no erythema or discharge. Tanner 1 breasts and pubic area. Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left with any balance, tries but tumbles; able to balance on each leg for 10 seconds. Cognitive Development: Able to state name and age; can write her own name; able to recall three friends names; knows all colors and can count to 13; dresses herself and has control of bowels and bladder; verbal throughout exam; all of speech clear and recognizable Assessment Primary Diagnosis 1. Wellness Child Exam ICD 10: Z00.129. In the wellness child exam the child is screened for immunization, growth and development, disease prevention and health promotion. Secondary Diagnosis 2 | P a g e2. Obesity ICD (10: E66.1) - Obesity according to the CDC (2017) is equal to or greater than the 95th percentile of a growth chart. The patient’s current BMI is 24% which places her above the 99th percentile for girls aged 5. 3. Behavioral insomnia (ICD 10: Z73.811)- Behavioral insomnia of childhood usually presents with perceived difficulties in initiating or maintaining sleep that require interventions by parents or other caregivers to overcome them (Ringdahl et al., 2004). a. This is a potential diagnosis for this patient as the parent states the child gets up to play in the room at night. 4. Anxiety (F41.1) -Lusk (2015) utilized the psychodynamic theory to describe anxiety as a conflict between the id and ego. As a direct consequence, aggressive and impulsive drives may be experienced as unacceptable resulting in repression. These repressed drives may break through repression, producing automatic anxiety (Lusk, 2015). Cognitive theory has explained anxiety as the tendency to overestimate the potential for danger (Lusk, 2015). a. This is evident in the child’s refusal to sleep alone or in own bedroom. 5. Nightmares (ICD 10: F51.5) - Vivid, frightening dreams that the child awakens from and has good recall of. Plan 1. Medications: a. Continuance of home multivitamin b. In office vaccinations: i. Rotavirus (RV): The patient is missing vaccinations for the Rotavirus. The vaccine can be given 4-10 weeks apart and totally three dosages. (CDC, 2017)-Administration Instruction: Rotarix 1.0 ml oral ii. Hepatitis B (HepB) vaccination: Dose one was previously given at 6 months of age the second dosage can be given on this visit. Dose two to Dose three can be given eight weeks at this visit and at least 16 weeks after the first dosage. - Administration Instruction: 0.5 ml Intramuscular injection iii. Diptheria, tetanus & acellular pertussis (DtaP) 5th dosage (CDC, 2017)- Administration Instruction: 0.5 ml Intramuscular injection iv. Inactivated poliovirus (IPV) 4th dosage (CDC, 2017)- Administration Instruction: 0.5 ml intramuscular injection or subcutaneous injection v. Measles, mumps, rubella (MMR) 2nd dosage (CDC, 2017)- Administration Instruction: 0.5 ml subcutaneous injection vi. Varicella (VAR) 2nd dosage (CDC, 2017)-Administration Instruction: 0.5 ml subcutaneous injection 2. Additional diagnostic tests: not at this time 3. Patient education a. Nutrition/physical activity (AAP, 2017): Provide a healthy breakfast every morning. Family meals as an alternative to processed and prepackaged foods. Offer a variety of healthy foods and include 5 servings of fruits and vegetables every day. Limit television video and computer games in order to establish a routine and promote educational growth and development. Physical activity and adequate sleep equivalent to 9-10 hours of sleep. Proper monitoring can be achieved through a food dietary log book that also has miscellaneous columns to also assess sleeping pattern and duration. b. Anticipatory Guidance: Discipline for teaching not punishment (AAP, 2017)- Target age range: It is important to note according to Scholer, Hudnut-Beumler, and Dietrich (2010) at three to five years of age most children are able to accept reality and limitations act in ways to obtain others approval and be self-reliant for 3 | P a g eimmediate needs. Educational points: In the same manner, the mother must understand that the child has not internalized many rules and judgment for situational response may not be appropriate. Scholer et al. (2010) recommend good behavioral models after which to pattern their own behavior. The consistency should apply not only in the rules and actions of the primary caregiver but in other adults who care for the child. Being that Kayla’s parents are in the home it is imperative that they share this plan with them as well. The patient at this age will still rely on verbal rules and the child will need supervision to carry through directions and for safety. Time-outs are an example of an effective technique that can be used if the child loses control. Redirection of small consequences related to and immediately following the misbehavior and other alternative. Approval and praise are the most powerful motivators for good behavior. Lastly, lectures are not effective and can be considered counterproductive given the level of development. 4. Referral a. Dental Referral: It is not stated in the vignette if Jo has seen a dentist as such this is appropriate to address. The American Academy of Pediatric Dentistry (AAPD) recommends that a child go to the dentist by age 1 or within six months after the first tooth erupts. Tooth decay is one of the most common chronic conditions of childhood in the United States. Untreated tooth decay can cause pain and infections that may lead to problems with eating, speaking, playing, and learning. About 1 of 5 (20%) children aged 5 to 11 years have at least one untreated decayed tooth b. Vision & Hearing screening. By age three, the American Optometry Association recommends that the child have a thorough optometric eye examination to make sure his or her vision is developing properly and there is no evidence of eye disease. Reviewing the results Snellen exam 20/40 in each eye, 20/30 together of the Snellen eye chart for this patient there are areas of concern. 5. Plan to follow up: In office visit within three weeks to assess the effectiveness of a dietary log book, increase in exercise, and vision and hearing screenings. KAYLA 37 YEAR OLD FEMALE Subjective Chief complaint: trouble falling and staying asleep, with ongoing fatigue History of present illness (HPI): Kayla reports that she is healthy and takes no medication. She has no symptoms that she can think of other than she is currently having trouble falling and staying asleep, but associates this with stress and with sleeping in the same room with her two younger children. She is a 15-year smoker of