Initial Visit: Meet the Family- SOAP Notes Case B: Part One
Background: Field Family: Mother: Michelle age 25, Father: Mike age 27, Daughter: Jennifer age 5, Son: Rey age 18 months. Maternal Grandmother: Mary age 48, Paternal Grandfather: Tom age 52.
Setting: Rural U.S.
Office: Rural, NP owned, Family Practice Clinic
Today is a busy day in your rural family practice clinic. You are reviewing the chart of your next appointment and realize that there is very little information and that you are scheduled to do well-child exams on a male age 18 months and female age 5 years, who appear from last names to be siblings. Your office schedules 20 minutes each for well-child exams. Upon entering the room, you note a Caucasian woman who appears in her early 30s who sits focused on paperwork, a male toddler climbing on the exam table to reach up and take the otoscope off of the wall, while a preschool-aged appearing female is sitting at your computer pretending to type on the keyboard.
As you introduce yourself, the mother stands abruptly and grabs the toddler off of the exam table, smacking his hand and causing him to cry, while simultaneously yelling “I told you to stop it!” She states, “I am so sorry. They usually behave. I am Michelle, and this is Rey and Jennifer.” You then inquire as to the reason for their visit, as you always do. The mother reports they recently moved to the area to live with her parents due to a recent separation from her husband, and she is there to have a physical exam before they lose her husband’s health insurance benefits. She reports that the children are currently healthy and have a regular pediatrician back at home.
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. 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. They do brush 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.
PMH: Jennifer: Full-term gestation, born cesarean section, weight. 7lb 4 oz. There were no complications in pregnancy, but the mother did smoke 1 PPD throughout pregnancy. There were no hospitalizations—NKDA. The daily medication was chewable children’s multivitamin with iron. Rey: Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Rey has allergies per mother and sometimes takes Cetrizine syrup half a teaspoon once daily, PRN congestion, and a children’s chewable multivitamin daily.
Immunizations: The mother has no immunization records with her at this time on either child. She reports some immunizations given, but cannot remember last date.
Social History: Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jennifer will be starting kindergarten this fall in the community’s elementary school.
Family History: They are maternal and paternal smokers. The mother has been one since age 16 at 1PPD until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia. MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF 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 32 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.
Note: Please answer these questions first. Your goal for this case is to build good differential diagnosis. The second part of this case will be adding the differential diagnosis and plan of care
Physical Examination Jennifer:
V/S: Ht: 105 cm, Wt: 17 kg, B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, non-labored, 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 bil.
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.
MUSCULOSKELETAL: MAE. Able to do deep knee bends; hop on one foot on right leg but not left; able to balance on each leg for 5 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.
Physical Examination Rey:
V/S: Ht: 83cm, HC: 48cm, Wt: 12.3 kg, B/P: 82/50, T: 98.6, HR: 112 BMP/reg., Resp: 24, reg, non-labored, SpO2: 97%
General: Active and cries throughout exam; fights being held for exam; calms quickly once exam is over. HEENT: Head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjuctiva clear, non-icteric, PERRL; unable to complete fundoscopic exam; tympanic membranes intact with scant clear fluid posteriorly bil; EAC unremarkable; pinna/tragus w/o tenderness; nares patent, mucosa pale, sl. edema in inferior and medial turbinatesbil, scant clear rhinorrhea; pharynx with mild posterior cobblestoning, tonsils 2/4 bil; primary tooth eruption to include all incisors, canines, and first molars on the lower, upper incisors and first molars; no loose teeth; some yellow discoloration noted to top left central incisor; oral exam unremarkable; neck supple with mild anterior cervical lymphadenopathy bil; thyroid small, firm, equal bil.
CARDIOPULMONARY: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal, intact bil radial and pedal; GU—both testes present. MUSCULOSKELETAL: MAE; able to run in the room and climb on the exam table.
COGNITIVE DEVELOPMENT: Verbalizes five words: mama, dada, drink, juice, and no; does babble; majority of speech unintelligible,able to feed self; not potty trained.
1-Include the ROS and what other historical information would you like to have at this visit?
2- What is the primary and secondary diagnosis for Jennifer and Rey with ICD-10 codes?
3-Include all your differential Diagnosis
- Since this visit is a well-child visit, Please include a plan of care for each patient (Jennifer and Rey). Provide any necessary education to the parent concerning this area.
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