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Evalynn M

DOB: 11/4/2019 Sex: F August/4/2023

Encounter Type: Office Visit

SUBJECTIVE:

Chief Complaint:

Patient is a 3-year-old female accompanied by parents presenting with intermittent cramping last

time. No more cramping today. That improved. Also had pruritus of the buttocks. That

improved. No more pruritus. Used to having regular daily bowel movements. Daily regular BM.

Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recent

illness. Patient denies any history of previous adverse reaction to vaccines. Patient have no

known allergies to medications.

Sick contact: dogs with pinworm

Social History:

Smoking Status: Never Smoked

OBJECTIVE:

Vital Signs:

Height: 104.50 cm

Weight: 17.35 kg

BMI: 15.89

Blood Pressure: 105/61 mmHg

Temperature: 36.50 C

Pulse: 105 beats/min

Resp. Rate: 24

Physical Exam:

Constitutional: Well developed. Well nourished. No acute distress.

Neck: Full ROM, trachea midline position

No thyromegaly

Respiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterally

No wheezing

Cardiovascular: No lifts, no heaves, or thrills No cyanosis

S1S2 RRR (-) murmur

No murmurs, rubs, gallops

Femoral pulses symmetrical

Chest/Breasts: Symmetrical No nipple discharge

No lumps, masses, or tenderness

Gastrointestinal (Abdomen): No masses or tenderness No hernias

Liver and spleen non-tender, not enlarged

Genitourinary: Female G/U: No external masses, lesions, scars

No vulvar rashes or swelling

Labia, clitoris, vaginal orifice, urethral meatus intact, without discharge

Lymphatic: No cervical adenopathy

(-) axillary adenopathy

No subclavian adenopathy

No epitrochlear adenopathy

(-) occipital adenopathy

Musculoskeletal: Digits are w/o clubbing or cyanosis

Equal leg length No back deformities

No misalignment, defects, or deformities

No Scoliosis No muscle atrophy or weakness.

Skin: Digits are w/o clubbing or cyanosis

Equal leg length No back deformities

No misalignment, defects, or deformities

No Scoliosis No muscle atrophy or weakness.

Neurological/Psychiatric: Normal tone Normal power Normal gait

ASSESSMENT:

Assessments:

ICD-10 Assessments:

3 year old girl for P/E.

Appropriate G and D

PLAN:

Immunizations:

Immunizations currently up to date.

Care Plan:

ANTICIPATORY GUIDANCE

No barriers to learning

Safety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,

passive smoke.

Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need for

independence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginary

playmates, enuresis.

Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,

repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and let

children choose).

BARRIERS TO LEARNING: Age Culture Religion

Language Emotional Limited Cognition

Limited Hearing Limited Vision

Readiness to learn Yes No

Learning preferences:

CBC PB PPD

Other lab:

Immunizations: (Check immunization card, document previous immunization, update if

necessary) DTaP No. HIB / HBV No. Prevnar No.

IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) Pentacel

RTC: days wks mos. PRN

Patient Instructions:

F/U for September Flu shot. Encouraged to drink extra prune juice twice a day: morning and

evening.

Evalynn M

Patient ID: 100294528 DOB: 11/4/2019 Sex: F Account No.:

Encounter ID: 283756022 Encounter Date: 07/21/2023

Encounter Type: Office Visit

SUBJECTIVE:

Chief Complaint:

Patient is a 3 year old female accompanied by parents presenting with intermittent cramping

10/10 abdominal pain x1 week, worsens at night. Also has pruritus of the buttocks. Parents report

seeing white dots on buttocks, possibly "eggs." Reports constipation, has 3 bowel movements per

week. Used to have regular daily bowel movements. Tried olive oil, which helped at first but did

not end up resolving symptoms. Tried prune juice with no improvement. Has been eating less,

small meals throughout the day.

Denies recent fever, cough, runny nose, difficulty to breathing, diarrhea, vomiting or recent

illness. Patient denies any history of previous adverse reaction to vaccines. Patient has no known

allergies to medications.

Sick contact: dogs with pinworm

History Of Present Illness:

Diet: picky / balanced diet; 3 meals/day, has been eating less

Sleep: 8 hours daily

Elimination: Tvoids 3-4 times per day.

Activity: Lives at home with mother, father, brother, and grandparernts. Attends daycare.

Sick contacts: none reported

Social History:

Smoking Status: Never Smoked

OBJECTIVE:

Vital Signs:

Height: 103.80 cm

Weight: 16.45 kg

BMI: 15.27

Temperature: 36.90 C

Pulse: 88 beats/min

Resp. Rate: 22

Head Circumference: 49.00

Physical Exam:

Constitutional: Well developed. Well nourished. No acute distress.

Eye: red reflex present bilateral PERRLA Sclera white, conjunctive clear No strabismus

Ear: No scars, lesions, or masses Canal walls pink, without discharge

Nose: Mucosa and turbinates pink Nares patent

Mouth: Gums pink Lips pink and symmetrical Oral mucosa pink / moist No cleft palate

Tongue moist, no ulcers

Neck: Full ROM, trachea midline position

No thyromegaly

Respiratory: Respiration non labored Good air entry No rales Clear to auscultation bilaterally

No wheezing

Cardiovascular: No lifts, no heaves, or thrills No cyanosis

S1S2 RRR (-) murmur

No murmurs, rubs, gallops

Femoral pulses symmetrical

Chest/Breasts: Symmetrical No nipple discharge

No lumps, masses, or tenderness

Gastrointestinal (Abdomen): No masses or tenderness No hernias

Liver and spleen non-tender, not enlarged

Genitourinary: Female G/U: No external masses, lesions, scars

No vulvar rashes or swelling

Labia, clitoris, vaginal orifice, urethral meatus intact, without discharge

Lymphatic: No cervical adenopathy

(-) axillary adenopathy

No subclavian adenopathy

No epitrochlear adenopathy

(-) occipital adenopathy

Musculoskeletal: Digits are w/o clubbing or cyanosis

Equal leg length No back deformities

No misalignment, defects, or deformities

No Scoliosis No muscle atrophy or weakness.

Skin: Digits are w/o clubbing or cyanosis

Equal leg length No back deformities

No misalignment, defects, or deformities

No Scoliosis No muscle atrophy or weakness.

Neurological/Psychiatric: Normal tone Normal power Normal gait

ASSESSMENT:

Diagnosis:

ICD-10 Codes:

1)B80; Enterobiasis

2)L290; Pruritus ani

3)R1084; Generalized abdominal pain

4)K5901; Slow transit constipation

Assessments:

ICD-10 Assessments:

3 year old girl for P/E.

Appropriate G and D

PLAN:

Procedures:

1) 99214; Office Visit Established Mod-High 25 min

Medications:

Mebendazole Powder; Take 1 tablet (100mg) and chew x 1; Qty: 1; Refills: 0

Immunizations:

Immunizations currently up to date.

Care Plan:

ANTICIPATORY GUIDANCE

No barriers to learning

Safety: Car seat, playground safety, sun exposure, falls, windows guards, pets, close supervision,

passive smoke.

Behavior: Praise good behaviors, handling undesirable behaviors (temper tantrums), need for

independence, sharing, exploration, provide choices, fantasy, fears, masturbation, imaginary

playmates, enuresis.

Other: Toilet training, brush teeth (no or little toothpaste), limit TV, reading (book types,

repetition, point and name, turn pages, fill in words, reading signs and labels, have variety and let

children choose).

BARRIERS TO LEARNING: Age Culture Religion

Language Emotional Limited Cognition

Limited Hearing Limited Vision

Readiness to learn Yes No

Learning preferences:

CBC PB PPD

Other lab:

Immunizations: (Check immunization card, document previous immunization, update if

necessary) DTaP No. HIB / HBV No. Prevnar No.

IPV No. FLU No. HBV No. HIB No. HAV No. MMR VZV PPD (if necessary) Pentacel

RTC: days wks mos. PRN

Patient Instructions:

- discuss about differential diagnosis of abdominal pain: constipation with diarrhea presentation

or hard stool,

- pinworm for itching perineal at night

- discuss that the diagnosis is based on identifying pinworm during night with scotch tape;

and discuss how to do it

- risk/benefits/alternative discuss about just treating it

- Constipation

- will give 3 days of pedialax at night in a row to clear possible diagnosis of constipation

- follow up in 2 weeks; may need another dose of mebendazole 100 mg/week

This is for next week problem soap note. Use the same template. (You can take your time)

3yrs old girl came twice to Doctor office. First time July. Second time Aug.

The reason was abdominal pain and constipation, pruritus(mom believed the abdominal pain is caused

by pinworm at that time by touching their dog))

However now all solved happily. You can modify the story.