week 7 ihuman soap note

Criteria

Clinical Notes

Subjective

Erin Wilson is a 5-year female with Trisomy 21 presenting for transfer of care and is s/p heart surgery at age 3 months for AV canal defect. Her current history is provided by her mother and includes concerns about her behaviors at preschool, falling asleep in the car and weight gain. ROS is positive for nocturnal enuresis (since birth), snoring (recent worsening ) and weight gain. Exam findings elevated BMI, typical phenotype for trisomy 21, a heart murmur, and enlarged tonsils. Erin’s chromosomal disorder places her at risk for multiple comorbid disorder.

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

Objective                

The patient has been observed that she is positive for obstructive sleep apnea. This does not in itself necessitate a surgical tonsillectomy. The patient will require comprehensive visit with an otolaryngologist to evaluate severity of symptoms, physical findings and risk factors.

The subclinical hypothyroidism might be contributing to both the weight gain and fatigue as exemplified by falling asleep in the caron the way from school. The treatment might result in improvement in both her fatigue and weight gain. And the adjustment disorder is consistent with her school behavior and is probably worsened by her cognitive delay. Ongoing counselling and individualized education should help alleviate her symptoms.

Blood Chemistry/ Polysomnography-

Positive for Obstructive Sleep Apnea, Thyroid stimulating hormone is within borderline, hemoglobin is normal and glucose fingerstick is normal.

This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

Erin Wilson is a 5-year female with Trisomy 21 presenting for transfer of care and is s/p heart surgery at age 3 months for AV canal defect. Her current history is provided by her mother and includes concerns about her behaviors at preschool, falling asleep in the car and weight gain. ROS is positive for nocturnal enuresis (since birth), snoring (recent worsening ) and weight gain. Exam findings elevated BMI, typical phenotype for trisomy 21, a heart murmur, and enlarged tonsils. Erin’s chromosomal disorder places her at risk for multiple comorbid disorder.

Diagnosis:

·        Obstructive sleep apnea was shown to be positive on the sleep study. This dos not in itself necessitate a surgical tonsillectomy. The patient will require a comprehensive visit with an otolaryngologist to evaluate severity of symptoms, physical findings, and risk factors for surgery.

·        Obesity is diagnosed based on a BMI of >95th %ile. The patient’s weight and height need to be plot on growth curves specific for down syndrome and extrapolate BMI for that data.

·        Subclinical hypothyroidism might be contributing to both the weight gain and fatigue as exemplified by falling asleep in the car on the way from school. Thus, treatment might result in improvement in both her fatigue and weight gain.

·        Adjustment disorder is  consistent with her school behavior and is probably worsened by her cognitive delay. Ongoing counseling and individualized education should help alleviate her symptoms.

·        Nocturnal enuresis was evaluated as a possible acute problem. Since laboratory testing was normal, continued monitoring will occur.

·        Nutritional deficiency was screened for with a hemoglobin as iron deficiency in children is the most common dietary deficiency. Because of Erin’s history of “Picky eating” her parents will record a food dairy for review. Expanded laboratory testing may be indicated in the future.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

Medically obesity, obstructive sleep apnea and adjustment disorder will need to be treated immediately. The patient’s nutritional deficiency is also a great importance in assuring adequate growth in diet and exercise . Erin’s diet needs to be adjusted from too much carbs to an increase in fruits and vegetables. She will be placed on a balanced, calorie-controlled diet. Once the weight is controlled, the obstructive sleep apnea will improve positively.

At school, the teacher should use clear  visual work sheets which are not too complicated  to complete. Give her time to understand short, simple, spoken instructions. Encourage her to work with other children on a task where they can learn cooperation and social skills. Ongoing counselling and individualized education should help alleviate her symptoms.

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.