week 1

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Well Child Soap

USU

Physical Assessment MSN 572

January 10, 2021

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Well Child Soap

SUBJECTIVE:

ID: Manon is a 13-year-old female who came to the clinic for her annual wellness check. She is

not an established patient. She is in 8th grade and currently resides with her mother, father, and

siblings. Manon states she has not had a wellness check in a while. She has no complaints

currently.

Pt. M., DOB11/01/07, Age 13-year-old, African American identifies as female, arrived with

parents to the clinic but unaccompanied by parents during interview is a reliable source of

information.

CC: “I am here for my wellness exam”

HISTORY OF PRESENT ILLNESS (HPI): 13-year-old female is here for her wellness exam and

states she feels well and healthy. She does not recall when her last exam was. She is up to date on

her immunizations a flu shot. Denies any medication use apart from allergy medicine prn and an

expired Epi pen for emergency use r/t peanut allergy. She last saw her dentist July 2020 for

braces removal. She denies any complaints or concerns at this time. Patient presents as a reliable

historian.

PAST MEDICAL HISTORY: M. is a 13-year-old African American female who presented to

clinic for her routine wellness exam. Generally, she feels healthy. She was visiting the dentist

monthly until last July as she had her braces removed. She has a difficult time with her retainer

often forgetting to remove it prior to eating. Patient verbalizes that she is “pretty healthy.” Patient

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stated that she broke her R. clavicle at 2.5 years old due to jumping on the bed. No implications

post injury. Patient denies surgery. Pt. Verbalizes that she has had one episode of Swimmer’s ear

treated with antibiotics with which she cannot remember the name of at this time. Pt. Has been

treated for Eczema at the age of 9 which as treated topical creams and has since resolved.

PAST MEDICAL PROCEDURES: Patient denies surgeries or hospitalizations.

MEDICATIONS: Takes over the counter seasonal allergy medication (Claritin 10mg po once

daily prn) and carries an expired Epi pen in the event of an anaphylactic shock due to an allergic

reaction. Patient knowledgeable on how to utilize an Epi pen. Educated on obtaining a new Epi

pen that is not expired. Patient states taking antibiotics a long time ago for Swimmer’s ear. She

takes fish oil for omega-3 daily. Denies any additional vitamins or supplements.

ALLERGIES: Patient has severe allergy to peanuts as evidenced by shortness of breath,

wheezing, hives, and anaphylactic reaction. Patient also allergic to pollen, dust, and grass which

results in sneezing that reoccurs in the Fall and Spring season. No latex allergy noted.

LMP (as applies) – Patient stated she had her menses last week. Periods are regular and not

painful. Patient started menses at age of 11. Patient states she goes through about two pads per

day and period lasts about 5 days. Has one period a month.

FAMILY HISTORY- Mother and father have no medical problems. Maternal grandmother has

high blood pressure and paternal grandmother has Diabetes Mellitus type I. Patient never met

grandfathers. Patient has three sisters ages 15 and 13, 13-year-old who has an allergy to shellfish.

No smokers in the family or at home.

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE: Patient denies sexual partners.

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-TOBACCO USE/Vaping: Patient denies smoking or vaping.

-ALCOHOL USE: Patient stated she has tried alcohol by accident when father left alcoholic

drink on counter and she thought it was orange juice.

-DRUG USE: Patient denies drug use.

-MARITAL HISTORY: Patient denies marriage.

-EDUCATIONAL LEVEL: Patient resides with mother, father, and her siblings. She has a close

relationship with her parents. Full time student in 8th grade. Gets A’s and B’s in school.

-SOCIAL LEVEL: Patient verbalizes having a small group of friends and denies experiences

with bullying.

-EXERCISE/DIET: Patient verbalizes she has healthy home-cooked meals and offered examples

of foods such as potatoes, rice, chicken, and beef. Patient likes to swim and uses that as her

exercise every day at home. Eats fast food about once every two weeks. No weight changes have

been noted.

-SLEEP/STRESS: Patient is not under stress. She sleeps normally for about 6-9 hours at night.

Goes to bed at 11:00PM and wakes up at 8:00AM daily.

-SAFETY: Patient wears a helmet, knee pads, and wrist guards during any rollerblading or

bicycle riles. Patient maintains safety precautions and wears seatbelt in the backseat of her car.

IMMUNIZATIONS- Patient is up to date with all her immunizations appropriate for her age of

Tdap, Tetanus diphtheria, pertussis, HPV human papillomavirus all shots, meningococcal,

pneumococcal, hepatitis B, hepatitis A, polio, MMR measles, mumps, rubella, chickenpox

varicella, and flu shot done on 01/12/20.

SPIRITUAL AFFILIATION- Patient is of Christian faith.

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REVIEW OF SYSTEMS:

CONSTITUTIONAL: Denies any concerns and states that she is “pretty healthy.” No changes in

weight, no weakness, no malaise.

EYES: Denies any vision problems. No aids used for visual aid. Last eye exam performed

06/13/20.

EARS, NOSE, MOUTH/THROAT: Denies any headaches, seizures problems. Denies hearing

problems or earaches. States that she has a runny nose during the springtime due to allergies.

Denies rhinorrhea. Last Dental exam (July 2020). Denies dental problems. Denies any sore

throat, tonsillitis, or swallowing problems.

CARDIOVASCULAR: Denies heart problems, pain or chest discomfort, or high blood pressure.

No chest pain of SOB during exercise.

RESPIRATORY: Denies respiratory problems. Experiences shortness of breath and sneezing

during allergies.

GASTROINTESTINAL: Denies gastrointestinal problems, denies abdominal pain, blood stool,

or rectal bleeding. Denies any nausea, vomiting, constipation, or diarrhea. Pt has BM twice every

day.

GENITOURINARY: N/A

MUSCULOSKELETAL: Denies any musculoskeletal problems, joint swelling, or joint stiffness.

Denies pain.

INTEGUMENTARY/BREAST: Denies any rashes, acne, lesions, moles, or urticaria.

NEURO: Patient verbalizes that she experiences mood swings sometimes. Denies headaches,

dizziness, numbness, loss in sensations, or weakness. No seizure history noted.

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PSYCH: Denies depression or anxiety. Patient states she “Gets moody sometimes according to

the sister”.

ENDOCRINE: Declines heat or cold intolerance or any thyroid problems. Denies excessive

thirst.

HEMATOLOGIC/LYMPHATIC: Denies anemia, abnormal bruising, or bleeding.

ALLERGY/IMMUNOLOGY: Patient has allergy to peanuts, pollen, dust, and grass.

OBJECTIVE:

PHYSICAL EXAM:

VITAL SIGNS: P:80 BP:108/60 RR: 18 T: 97.8 Pain : 0/10

Ht : 58.5 inches tall Wt :46kg (102 lbs) BMI: 18.5 (25th percentile)

(Centers for Disease Control and Prevention, 2020)

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PHYSICAL EXAM:

General survey: Patient appears neat, well-groomed, and presentable.

HEENT:

Skin: Dry, pink, intact.

Eyes: extraocular motions full, conjunctiva clear. sclerae non-icteric, pupils' equal round

and reactive to light.

Ears: Tympanic membrane landmarks well visualized.

Nose: No discharge, no obstruction, septum not deviated.

Throat: lips pink, no gum or teeth abnormalities, tongue no lesions, no masses

Neck: Denies pain.

CV: Breasts symmetrical, nontender, no masses or discharges.

Pulmonary: Lungs: clear No dullness to percussion. Diaphragm moves well with

respiration. No rhonchi, wheezes or rubs.

Abdomen/GI: soft, flat, bowel sounds present, no bruits. Nontender to palpation. Liver

edge, spleen, kidney not felt. No masses.

GU: soft, flat, bowel sounds present, no bruits.

M/S: Full range of motions w/o any difficulties.

Lymph: No adenopathy

Skin: Clean, dry, intact, free of abrasions or contusions

Neuro: No history of seizures, stroke, syncope, memory changes, or headache

Psych: No history of depression, anxiety, depression, mood changes, or suicidal thoughts

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DIFFERENTIAL DIAGNOSIS:

1. Food Allergy Z91.018- Anaphylaxis: Patient has a severe allergy to peanuts evidence by

patient verbalizing that she experiences SOB and wheezing, which can result in

anaphylaxis and hospitalization. Patient currently has an expired EpiPen.

2. Wellness Exam Z00.129: The Academy of Pediatrics states that surveillance be performed

at each clinic visit for formal developmental screening. This is to be done at 9, 18, and 30

months (Turner, 2018).

3. Dietary surveillance and counseling Z71.3: “Healthy eating in childhood and adolescence

is important for proper growth and development and to prevent various health

conditions. The 2015–2020 Dietary Guidelines for Americans external icon recommend

that people aged 2 years or older follow a healthy eating pattern” (CDC, 2018).

FINAL DX: Wellness Z00.129. (ICD.CODES, 2020).

PLAN:

-Diagnostic plan: CBC for overall wellness check.

-Treatment/Therapeutic Plan:

New Rx given for two (2) EpiPen 0.3mg per 0.3 ml Auto-Injectors due to patient having one

expired EpiPen on hand. One dose of the EpiPen is to be used IM into the anterolateral aspect of

the thigh in the event of the patient ingesting peanuts r/t serve allergy reaction of anaphylaxis.

Referrals: None necessary for patient.

Education:

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1. Educate patient on the importance of having at least two EpiPen’s at hand and the significance

of carrying them for an unprecedented event of an anaphylactic reaction as evidence by a sever

allergy to peanuts. Would suggest the regular Epi Pen 0.3mg. per 0.3 ml IM prn for allergic

reaction.

2. Educate patient on the importance of a healthy diet such as eating a variety of vegetables and

fruits, whole grains, fat-free and low-fat dairy products, a good variety of protein- rich foods, and

healthy oils derived from fish and vegetables.

3. Educate patient on safety in relation to outdoor activities, particular to having an adult

supervision at all times during swimming to prevent a drowning related accident.

F/U Plan:

1. F/U in a week about patient getting EpiPen from pharmacy and comprehension level of patient

about using the pen properly.

2. Follow up in a month about dietary changes for maintaining a healthy weight and obesity

prevention.

References

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American Academy of Pediatrics. (2017). Bright futures: Guidelines for health

supervision of infants, children, and adolescents.

Centers for Disease Control and Prevention. (2019, May 29). Childhood Nutrition

Facts. https://www.cdc.gov/healthyschools/nutrition/facts.htm.

Centers for Disease Control and Prevention. (2020, February 2). Easy-to-read

immunization schedule by vaccine for ages 7-18 years | CDC.

https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-

easyread.html

Turner K. Well-Child Visits for Infants and Young Children. (2018, September 15) Am Fam

Physician;98(6):347-353. PMID: 30215922.