Assignment: Present Concerns\/CC<\/p>\n
Name: M. O.\tDate: 05\/21\/18
\nSex: Male\tAge\/DOB\/Place of Birth: 8 Y\/O \/04-20-2010\/Miami, Florida
\nSUBJECTIVE
\nHistorian: Dad
\nPresent Concerns\/CC:<\/p>\n
\u201cHe hurt his right arm.\u201d<\/p>\n
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare\/school\/after-school care; Sports\/physical activity; Developmental Hx)
\nHealthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.<\/p>\n
HPI: (must include all components)
\n8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.<\/p>\n
Medications: (List with reason for med )
\nNone.<\/p>\n
PMH:
\nAllergies: NKDA<\/p>\n
Medication Intolerances: None<\/p>\n
Chronic Illnesses\/Major traumas: None<\/p>\n
Hospitalizations\/Surgeries: None<\/p>\n
Immunizations: Updated<\/p>\n
Family History ( Please identify all immediate family)
\nFather alive and well, mother alive and well.<\/p>\n
Social History Education level, occupational history, current living situation\/partner\/marital status, substance use\/abuse, ETOH, tobacco, and marijuana. Safety status
\nHe lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.<\/p>\n
ROS
\nGeneral
\nDenies, headache, chills, myalgia.<\/p>\n
Cardiovascular
\nDenies chest pain\/discomfort, heart problems<\/p>\n
Skin
\nDenies rash or lesions.<\/p>\n
Respiratory
\nDenies cough, difficulty breathing, wheezing.<\/p>\n
Eyes
\nDenies discharge from eye, redness, or pain<\/p>\n
Gastrointestinal
\nDenies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.<\/p>\n
Ears
\nDenies pain or discharge<\/p>\n
Genitourinary\/Gynecological
\nDenies dysuria or changes in urinary pattern.<\/p>\n
Nose\/Mouth\/Throat
\nDenies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing<\/p>\n
Musculoskeletal
\nReports injury and pain to left arm<\/p>\n
Breast
\nDenies pain or tenderness<\/p>\n
Neurological
\nDenies loss of consciousness, dizziness, headache, or alteration in mental status<\/p>\n
Heme\/Lymph\/Endo
\nDenies weight loss, activity intolerance, heat or cold intolerance<\/p>\n
Psychiatric
\nDenies depression, anxiety, or suicidal ideation<\/p>\n
OBJECTIVE (plot height\/weight\/head circumference along with noting percentiles) Attach growth chart
\nWeight 30.3 kg\tTemp 98.9 F\tBP 97\/59 mmHg
\nHeight 50 in
\nBMI: 18.74<\/p>\n
Pulse 100 x\u2019\tResp 20 x\u2019
\nSp02<\/p>\n
General Appearance and parent\u2010child interaction:
\nNo acute distress, well-developed, well nourished, alert.<\/p>\n
Skin
\nSkin pink, warm, and dry, no rashes or lesions noted.<\/p>\n
HEENT
\nHead normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.<\/p>\n
Cardiovascular
\nS1S2 audible. Regular rate and rhythm. No murmurs.<\/p>\n
Respiratory
\nLungs clear, good air exchange, no wheezes or rales<\/p>\n
Gastrointestinal
\nAbdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly<\/p>\n
Breast
\nDeferred<\/p>\n
Genitourinary
\nBladder is non-distended; no CVA tenderness, external and internal genitalia not examined.<\/p>\n
Pediatric SOAP Note<\/p>\n
Musculoskeletal
\nLimited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.<\/p>\n
Neurological
\nAlert, moves all extremities spontaneously<\/p>\n
Psychiatric
\nAge appropriate development.<\/p>\n
In-house Lab Tests \u2013 document tests (results or pending)
\nRight wrist x-ray \u2013 closed fracture at distal radius<\/p>\n
Pediatric\/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
\nFor adolescents (HEADSSSVG Assessment)<\/p>\n
Diagnosis
\n\u00b7 1. Closed fracture of distal end of right radius \u2013 S69.91XA
\n\u00b7 Pertinent positives \u2013 reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-ray<\/p>\n
\u00b7 Pertinent negatives \u2013 no obvious deformity, no swelling<\/p>\n
\u00b7 Rationale \u2013 Limited ROM following injury or trauma to the arm suggest possible fracture.<\/p>\n
2. Other specified sprain of right wrist, initial encounter \u2013 S63.591A<\/p>\n
\u00b7 Pertinent positives \u2013 reports recent injury to left arm, limited ROM to right wrist, pain with ROM<\/p>\n
\u00b7 Pertinent negatives \u2013 no obvious deformity, no swelling<\/p>\n
\u00b7 Rationale \u2013 Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain.<\/p>\n
3. Dislocation of right wrist \u2013 M24.331<\/p>\n
\u00b7 Pertinent positives \u2013 reports recent injury to left arm, limited ROM to right wrist, pain with ROM<\/p>\n
\u00b7 Pertinent negatives \u2013 no obvious deformity, no swelling<\/p>\n
\u00b7 Rationale \u2013 Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation.<\/p>\n
\u00b7<\/p>\n
\u00b7 Primary diagnoses: Closed fracture of distal end of right radius \u2013 S69.91XA<\/p>\n
PLAN including education<\/p>\n
\u00b7 Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)<\/p>\n
\u00b7 Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note provided<\/p>\n
\u00b7 Administer Tylenol or Motrin every 4-6 hours as needed for pain.<\/p>\n
\u00b7 Follow-up with Orthopedics, copy of x-ray CD provided<\/p>\n
\u00b7
\nReferences
\nArora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http:\/\/dx.doi.org.southuniversity.libproxy.edmc.edu\/10.3928\/00904481-20140417-12<\/p>\n","protected":false},"excerpt":{"rendered":"
Assignment: Present Concerns\/CC Name: M. O. Date: 05\/21\/18 Sex: Male Age\/DOB\/Place of Birth: 8 Y\/O \/04-20-2010\/Miami, Florida SUBJECTIVE Historian: Dad Present Concerns\/CC: \u201cHe hurt his right arm.\u201d Child […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"pagelayer_contact_templates":[],"_pagelayer_content":"","footnotes":""},"categories":[1942],"tags":[1944,1839,1838,1837],"class_list":["post-5543","post","type-post","status-publish","format-standard","hentry","category-write-my-psychology-papers","tag-write-my-psychology-research-paper","tag-psychology-research-papers","tag-psychology-dissertations","tag-psychology-assignment"],"_links":{"self":[{"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/posts\/5543","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/comments?post=5543"}],"version-history":[{"count":0,"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/posts\/5543\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/media?parent=5543"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/categories?post=5543"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.homeworkacetutors.com\/acemyhomework\/wp-json\/wp\/v2\/tags?post=5543"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}