Peds Wellness Visit

SOAP Note Peds Wellness Visit Chief Complaint: “My child needs a physical for school” History of Present Illness: Z. M. is an 18 month old healthy appearing African-American female who presented to the clinic for a routine 18 month well-child visit. She lives with both parents and both are present for this appointment. She has one older sibling who is also in daycare. Her parents are attentive to her during this visit and both are answering questions about her developmental milestones. Mom reports that she eats very well and denies her being a picky eater. She reports that Z.M. drinks 8- 16 oz. of whole milk a day from a cup and feeds herself a variety of table foods without issue. Z.M. is reported by her parents to sleep through the night in her own bed. She goes to bed between 8p-830p each night. She does not use a bottle, sippy cup, or pacifier at bedtime. Her father reports that she does not use a pacifier in general. He also reports brushing her teeth twice daily. Mom reports that she interacts as she expects her to with new situations and with her peers in daycare. Mom denies that the daycare provider has reported any concerns. Both parents deny any concerns at this checkup and both parents agree she is on track since her last well child visit at 15 months of age. Past Medical History: Z.M. has had no major illness to date. She has no history of major problems. Her history does include: Immunizations up to date for age: 2/12/2019 - Hep B 4/15/2019 - RV, HIB, PCV 13, Pediarix (DTap, Hep B, IPV) 6/12/2019 - Pentacel (DTap, IPV, Hib), PCV, RV 8/12/2019 - Pediarix (DTap, IPV, HepB), Hib, PCV, RV 2/14/2020 - MMR, Varicella, HepA 5/25/2020 - DTap, Hib, PCV - Hep A vaccine today (9/1/2020) Surgical History: Denies surgical history per parents Allergies: No Known Allergies Medications: None Family History: Mother, 31yo - no health history Father, unknown Grandfather, deceased 72 yo - MI Grandmother, 82 yo – cataracts, HTN Uncle 35yo - depression, bipolar Social History: Resides in a 2nd floor apartment with her boyfriend and daughter, mother reports a good support system. Parents deny tobacco use, alcohol intake, or illegal drug use. Z.M. attends daycare Monday through Friday. Sits in a 5-point harness car seat with latch system Review of Systems: General: Denies weight loss, fever, night sweats, fatigue, malaise and chills HEENT: Denies vision changes, difficulty hearing, runny nose, mouth sores, loose teeth, ear pain, sore throat, and neck pain RESP: Denies cough, sputum, wheezing, and dyspnea CV: Denies cyanosis, swelling, erythema of skin GI: Denies constipation, abdominal pain, nausea, vomiting and diarrhea GU: Denies dysuria, urinary frequency, discharge, and history of sexually transmitted infections MS: Denies recent trauma, falls, back pain, joint swelling, stiffness or pain, and/or fracture history SKIN: Denies rash, lesion, or color changes NEURO: Denies headache, syncope, tremors, numbness, difficulty speaking, and loss of consciousness PSYCH: Denies difficulty sleeping, behavioral changes, concerns for growth/development, and hyperactivity Physical Exam: Vitals: T 97.9F (36.6C) oral | Pulse 93, regular| Resp 24 | BP 97/67 | Wt 26lb (78.6 kg) | Ht: 32.8in | SpO2 98% | BMI 17.3 kg/m2 GENERAL: Well nourished, clean, appears to be in no distress, cognitive function appropriate to age HEAD: Normocephalic and hair evenly distributed; no lesions EYES: PERRLA, sclera white, extra ocular movements intact; no hemorrhage or exudate noted. EARS: External auditory canals and tympanic membranes clear NOSE: Nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge NECK: Neck symmetrical, supple, full ROM, non-tender without masses THROAT/MOUTH: Oral mucosa pink and moist; dentition is good; pharynx w/o erythema, exudates, or lesions. LUNGS: Bilaterally clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds CV: Regular rate and rhythm, normal sinus rhythm with S1, S2 normal; no murmur, clicks, rubs, or gallop GI: Positive bowel sounds in all four quadrants. Soft, non-distended, non-tender; no guarding, rebound, or masses noted SKIN: Warm, dry, and intact, capillary refill < 3sec.; no rash, lesion, pallor or cyanosis noted MS: Full range of motion in all four extremities, grossly normal function and strength of extremities. No bone, joint, or muscle tenderness or swelling. NEURO: Speech clear. Posture erect. Balance stable; gait normal. Symmetric movements, reflexes grossly intact, no focal deficits. PSYCH: Mood and affect appropriate. Well-adjusted and comfortable during exam. Growth Chart/Developmental Assessment Tool: Autism Spectrum Disorder (MCHAT): Score 1, low risk; no follow-up needed 18 month ASQ: Results: Development is on schedule; no further action taken at this time Lab Data/Tests: H/H - 11.4/34.3 (9.9-17.3)/(29-44) - 2/14/2020 Lead - <1.9 (0-5) - 2/14/2020 TB Risk assessment: TB test not needed Differential Diagnosis: N/A Definitive Diagnosis: N/A Therapeutic Plan: 1. HepA vaccination given today; VIS provided 2. MCHAT for Autism screening and she passed this screen without concern 3. Discussed anticipatory guidance based upon the Bright Futures Guidelines developed by The American Association of Pediatrics (AAP) 4. Return in 6 months for 2 year old visit Health Promotion: Most of the injuries to children under 2 years occurred in the home. According to the Center for Disease Control and Prevention (CDC) (2019), children 1 to 4 years of age had the highest rates of nonfatal falls and poisoning. Injury prevention and safety recommendations in regards to childproofing the home include keeping medications and cleaning supplies out of reach, guarding the stairs and outlets, and keeping children away from heavy/hot objects (Schnitzer, 2006). Health Education: The establishment of eating practices that contribute to lifelong nutritional habits and overall health begins in toddlerhood. For that reason, the American Academy of Pediatrics (AAP) use of whole milk until 2 years of age is highly recommended compared to reduced fat milk (Riley, Rupert, & Boucher, 2018). Cow's milk provides key nutrients, such as protein, calcium, and vitamins A and D; therefore a recommendation of two 8-oz servings of cow's milk per day in toddlers to maintain adequate vitamin D and iron stores. The AAP also recommends that toddlers drink whole dairy milk since they need the fat for proper development of their brains and nervous systems.