Assignment: Patient Encounters into CORE.

Assignment: Patient Encounters into CORE. 

Assignment: Patient Encounters into CORE. 

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment: Patient Encounters into CORE. 

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using the Pediatric SOAP Note template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Dropbox. When submitting your note, be sure to include the reference number from CORE.

 

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You

 

Pediatric SOAP Note

 

Patient Initials: M.R

 

Date of Encounter: 05/03/2019

 

Sex: Female

 

Age/DOB/Place of Birth: 15years old/ 10/08/2003

 

SUBJECTIVE

 

Historian: Mother

 

Present Concerns/CC:

 

“We have an appointment today for my daughter wellness checkup and update immunizations.”

 

Child Profile:

 

MR is a Fifteen years old Hispanic female patient who comes to the clinic today accompanied by her mother for a routine wellness annual exam and immunizations. MR lives with her biological parent’s and was delivery through a normal vaginal birth, and the pregnancy was full term without complications. MR does not have a history of chronic diseases, reports feeling well since the last consult and have proper growth and developmental state. The patient states that she sees her periods every month and they last for three days and denies any sexual activity. Patient’s mother inquires about what vaccines the child needs at this time.

 

HPI:

 

MR is a 15 years old teenager brought to the clinic today by her mother for her annual wellness exam. Pt’s mother denies any child history of chronic disease, complication or any concern at this time. The mother reports no previous injuries that have required medical attention and update immunizations.

 

Medications:

 

Tylenol 500mg every eight hours as need it during menstrual periods.

Medication Intolerances: None

 

Chronic Illnesses/Major traumas: no reported

 

Hospitalizations/Surgeries: hospitalized for two days due apendicectomy five years ago.

 

Immunizations: Up to date

 

Family History

 

Both parents are alive and healthy. Mother 35 years old without Hx of any disease and father 38 years old, Obese. Pt has a little sister age five who is active and healthy as well. Pt grandparents are alive and suffer from some chronic diseases like Maternal grandmother has COPD and hypertension, and maternal grandfather is recovering from CVA. The paternal grandmother and father are healthy since now.

 

Social History

 

The teen lives with both parents in a nuclear family with good social/financial status. None of the parent’s smoke or consumes alcohol or any drugs. The patient reports that she is not sexually active and is attending high school with good grades. Pt denies the use of recreational drugs. The patient has a great support system from the parents and the rest of the family. Pt states that have excellent communication with her mother.

 

ROS

 

General

 

Pt well nourished very healthy who has good growth and development for her age. No weight changes. No fever, fatigue, chills, night sweats, or lethargy.

 

Cardiovascular

 

Patient denies any history of murmur or cardiac issues, no edema, or orthopnea at this time.

 

Skin

 

Denies delayed healing, rashes, eczemas, lumps, bruising, itching, dryness, bleeding or skin discolorations, any changes in lesions or moles.

 

.

 

Respiratory

 

Negative for dyspnea, cough, wheezing, or tachypnea

 

Eyes

 

Symmetric. Parent denies eye redness, or drainage.

 

Gastrointestinal

 

Negative for nausea, vomiting, diarrhea or constipation.

 

Ears

 

Patient denies ear pain, or problems with hearing or discharge.

 

Genitourinary/Gynecological

 

Denies urgency, frequency, burning sensation during urination, and change in color of the urine. No vaginal discharge

 

pampers.

 

Nose/Mouth/Throat

 

No symptoms of nasal discharge, congestion, nose bleed, sinus pain, post nasal drip, difficulty in swallowing, and mouth ulcers

 

Musculoskeletal

 

Negative for back pain. Denies joint swelling, stiffness or pain, fracture history.

 

Breast

 

Patient denies breast tenderness and lumps.

 

Neurological

 

Alert and orient in time, place and person. Good psychomotor development for her age. No history of seizures and other neurologic alterations.

 

Heme/Lymph/Endo

 

Negative for bruising, blood transfusion history, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.

 

Psychiatric

 

Denies sleeping difficulties, or any previous psychiatric disease. Doing well at school. Good attention span.

OBJECTIVE

 

Height: 155cm

 

Weight:110 Pounds

 

BMI:20.8

 

Growth Chart (Between 50-75 percentile (61th)

 

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You 1

 

Weight 110 lbs.

 

Temp 98.5 F

 

BP 104/62 mmHg

 

Height 155cm

 

Pulse 65 bpm

 

Resp 17 x min

 

General Appearance and parent‐child interaction:

 

Teen appears to be well-nourished, in no distress. Cooperative for the exam, interacting appropriately with examiner and mother. Normal weight, healthy, well-developed, alert and oriented, on no distress. Well groomed, pleasant, answers questions appropriately.

 

Skin

 

Skin is appropriate for ethnicity; warm, dry and intact. Negative of rashes or lesions. Good skin turgor

 

on examination.

 

HEENT

 

Head: Normocephalic, no traumatic and no lesions noted; hair is uniformly distributed.

 

PERRLA, Normal conjunctiva and sclera. Pupils are responsive to light and extra ocular movements intact. Funduscopic exam shows no papilledema. No history of dental caries. Ears: External appearance is normal with no swelling or lesions.

 

Cardiovascular

 

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

 

noted. No cyanosis, no clubbing.

 

Respiratory

 

Good respiratory pattern. Bilaterally clear to auscultation without rhonchi, crackles, wheezes or

 

rales. No dullness on percussion, good excursions

 

Gastrointestinal

 

Abdomen soft, non-distended and non-tender to palpation. No guarding or rigidity, no masses are present. A little scar of two cm in right lower quadrant (appendectomy).

 

Breast

 

Symmetric, normal in texture and skin color, no nipple discharge. No presence of mass and pain

 

during examination. Tanner stage like adult.

 

Genitourinary

 

Menarche at 12, sees period regularly and last for around three days. All secondary

 

sexual characteristics present, Tanner stage: adult like, fully developed breast and pubic hair.

 

Pt reports she is not sexually active. No lesions to external genitalia noted.

 

Rectal exam: Differed.

 

Musculoskeletal

 

No joint deformities. Bilateral upper and lower extremities equally and with normal configuration. Normal Full ROM in all extremities as patient moved about the exam room.

 

Neurological

 

Alert and oriented x 4. Speech clear. Cranial nerves II to XII intact. Good tone. Posture erect. Balance stable; gait normal.

 

Psychiatric

 

Dressed clean and appropriately. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

 

In-house Lab Tests – document tests (results or pending)

 

Done in Office:

 

Snellen chart OU=20/20, OS=20/20, OD=20/20.

 

Normal hearing

 

Random glucose test (88mg/dl).

 

Hb 12.6 mg/dl

 

Urine dip test: Negative.

 

No need for further testing at this point.

 

No diagnostic tests were ordered during this visit.

 

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc.) with results and rationale

 

HEADSSSVG Assessment for adolescents was conducted and no evidence of depression was found.

 

ASSESSMENT (Diagnosis: Primary and Differentials)

 

1- Primary diagnosis (Z00.129): Encounter for routine child health examination w/o abnormal finding

 

2- Differential diagnoses: N/A

 

PLAN (including education)

 

Vaccines administered: Teen received INFLUENZA VACCINE.

 

Vaccine administration forms given

 

Education: The parent should keep closed communication with the teen all over so that they be able to note any changes to their well-being with no trouble. They should also provide proper training and guidance to the child on the probable diseases that can affect them in the last phases of life so that she will be better prepared psychologically and able to handle it successfully. We should not forget that educate the child on safety is vital, and the security actions should be efficiently spoken to the child to prevent any damages that can negatively affect their health. Also, it is essential to maintain a healthy diet which will help with the proper growth and will prevent obesity which has been changing the children leading to diseases as HTN and Type II DM. Though this Pt. is adequately vaccinated according to schedule, is also essential to enforce the importance of vaccination in the prevention of transmissible diseases and its complications.

 

Anticipatory Guidance: Parent should be advised that they must keep closed attention to the adolescent mood as sometimes depression goes unnoticed and suicide is one of the most common causes of death at this age altogether with accidents and drug/ETOH use and abuse.

 

Follow up/Referrals: No referrals needed at this time.

 

References

 

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G. (2017). Pediatric Primary Care, 6th Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780323243384/

 

Centers for Disease Control and Prevention. (2018). Developmental Monitoring and Screening for Health Professionals. Retrieved from https://www.cdc.gov/ncbddd/childdevelopment/screening-hcp.html

 

Evan G. Graber, DO, Clinical Assistant Professor of Pediatrics; Pediatric Endocrinologist, Sydney

 

Kimmel Medical College; Nemours/Alfred I. duPont Hospital for Children

 

http://www.merckmanuals.com/professional/pediatrics/growth-and-development/physical-growth-of-infants-and-children

 

Goolsby, M. J. & Grubbs, L. (2014). Advanced assessment: Interpreting findings and formulating differential diagnoses, (3rd ed.). Philadelphia, PA: F. A. Davis. ISBN: 9780803643635