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Assignment Prompt Select a patient. You may use a peer, friend, or family for this assignment, but they must be 18 or older. 65-year-old female presents to the clinic for a wellness exam and states he healthy. His last exam was in 2019. He is up to date on his immunizations, flu shot , and COVI-19 vaccine x2 4/2021. Denies any prescription use. Last dental exam was on august 5th 2021 for routine cleaning. Uses glasses with a previous eye exam in 2020 No eye prescription changes on the visit. He denies any · complaints or concerns at this time. The patient presents as a reliable historian. She is a Christian, had 6 children, no medical hx, she does not smoke or drinks any alcohol. · Obtain a complete health history from this “patient” · Have the patient pretend they are visiting you for a “well exam” or “annual check up” (as opposed to a problem focus) and use the health history template posted in the course. · DO NOT perform any physical exam. You are only doing the interview portion of the patient visit for this assignment. · Document your findings as you would for a comprehensive visit, including a risk assessment (at least three risks with rationale) in your assessment. · Submit this write-up of the history and risk assessment via the assignment tab. Expectations · For write up, follow format in Example Health History Worksheet posted in this module 1 History Video and Risk Assessment RN, BSN United States University MSN 572- Advanced Health and Physical Assessment Across the Lifespan Dr. O May 10, 2021 This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 2 SOAP Video link https://studio.youtube.com/video/YV5L-FnZwNQ/edit SUBJECTIVE: ID: B.G. age 32, Hispanic male, DOB 06/11/1988. Presents to the clinic for a wellness check per job. Came to clinical by himself. He currently resides with his girlfriend. The patient’s last wellness exam was in 2019. Not sure of specific dates. He has no current complaints. CC: “A wellness check.” HISTORY OF PRESENT ILLNESS (HPI): 34-year-old male presents to the clinic for a wellness exam and states he healthy. His last exam was in 2019. He is up to date on his immunizations and flu shot 9/2020 and COVI-19 vaccine x2 2/2020. Denies any prescription use. Last dental exam in 2019 for routine cleaning. Uses glasses with a previous eye exam in 2019. No eye prescription changes on the visit. He denies any complaints or concerns at this time. The patient presents as a reliable historian. PAST MEDICAL HISTORY Denies past medical problems PAST MEDICAL PROCEDURES Tonsillectomy at nine years old on 03/03/2000 MEDICATIONS Claritin- seasonal allergies PRN Men’s Gummy Multivitamin- daily This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 3 ALLERGIES Seasonal allergies- pollen. Seasonal Food- denies food allergies Medications- denies LMP (as applies) N/A FAMILY HISTORY Mother- 50 yr. old female who is healthy with no medical problems Father- 51 yr. old male who is healthy with no medical problems Brother- 26 yr. old male who is healthy with no medical problems Sister- 27 yrs old female who is healthy with no medical history. Maternal grandmother- in the 80’s. no medical history Maternal grandfather- in the ’90s has a history of emphysema and COPD from cigarette smoking Paternal grandmother- 80’s, has a history of D.M.- insulin-dependent Paternal grandfather- unknown SOCIAL HISTORY -SEXUAL/REPRODUCTIVE- reports in a monogamous relationship for the last three years with a female. Denies use of contraceptives. Partner is on birth control -TOBACCO USE/Vaping: pt denies smoking and vaping. Denies being around people who smoke -ALCOHOL USE: social- 2-3 beers a week. -DRUG USE: denies illicit drugs. Denies being around people who use drugs -MARITAL HISTORY: not married, 3-year long relationship with a girlfriend. Lives with girlfriend in a home that is owned -OCCUPATION: Emergency room director a Banner Health Hospital This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 4 -EXERCISE/DIET: Does cross-fit three times a week. Meal prep with high protein diet Pt denies eating red meat. Eats lean white meat. Chicken preferred—insufficient vegetable intake. Pt eats 2-3 servings of fruit a day. Drinks1 gallon of water a day. -SLEEP/STRESS: sleeps an average of 7-8 hours a night. Pt reports no difficulties falling asleep. Pt feels rested and not tired throughout the day. IMMUNIZATIONS Up to date immunizations. Flu vaccine on 09/2020 and is fully Covid-19 vaccinated with a second dose given on 02/2021 SPIRITUAL AFFILIATION Pt states he is Catholic. Pt is active with the church community attending Sunday mass weekly via skype. REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies weight changes or decreased appetite. EYES: he has had glasses since pt was nine years old. The last eye exam was two years ago. Denies redness or drainage—previous eye exam in 2019. EARS, NOSE, MOUTH/THROAT: denies hearing loss, discharge, and earache, reports rhinorrhea, sneezing, stuffiness during seasonal allergies, denies pain or difficulty swallowing. Last dental exam two years ago. 2019. CARDIOVASCULAR denies angina, palpitations, and dyspnea RESPIRATORY: Denies wheezing and shortness of breath; pt reports deny dry cough with allergies cough and denies sputum production. GASTROINTESTINAL: denies dysphagia, constipation, diarrhea, and abdominal pain, denies rectal or history colon cancer. Denies having a colonoscopy. Daily B.M., soft brown stools GENITOURINARY: denies scrotal pain, nocturia, urinary urgency or frequency, incontinence, libido changes, Denies scrotal pain, weak stream, or erectile dysfunction MUSCULOSKELETAL joint pain, joint swelling, muscle pain. INTEGUMENTARY/BREAST: Denies eczema, excessive dryness, and discoloration. Denies breast pain. This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 5 NEURO: denies seizures, headaches, memory loss PSYCH: denies anxiety, depression, psychosis, bipolar ENDOCRINE: Denies heat or cold intolerance, weight changes, libido, or sexual performance HEMATOLOGIC/LYMPHATIC: Denies easy bruising, anemia ALLERGY/IMMUNOLOGY: Denies drug/food/ allergies, environmental allergies pollen OBJECTIVE: Ht : 5’10” Wt. : 210 BMI: 30.1 RISK ASSESSMENT: 1) Risk of diabetes due to BMI 30.1 and paternal grandmother is a diabetic and insulin- dependent. Overweight and especially obesity, particularly at younger ages, substantially increases the lifetime risk of diagnosed diabetes, while their impact on diabetes risk, life expectancy, and diabetes duration diminishes with age (Narayan et al., 2007). Even a moderate elevated BMI is associated with an increased risk of developing D.M. complications (Gray et al., 2015). 2) Risk for depression- healthcare workers in acute care due to the COVID-19 pandemic. Healthcare workers, who are at the forefront of the fight against COVID-19, are particularly susceptible to physical and mental health consequences such as anxiety and depression (Sahebi et al., 2021). 3) Risk of nutritional deficiency- due to not eating vegetables. Sufficient intake of fruits and vegetables has been associated with a reduced risk of chronic diseases and body weight management, but the exact mechanism is unknown (Pem & Jeewon, 2015). Eating vegetables provides health benefits- people who eat more vegetables and fruits are part of This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 6 an overall healthy diet are likely to have a reduced risk of some chronic disease (Vegetables | MyPlate, 2020). This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:08 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ 7 References Gray, N., Picone, G., Sloan, F., & Yashkin, A. (2015). Relation between BMI and Diabetes Mellitus and Its Complications among US Older Adults. Southern Medical Journal, 108(1), 29–36. https://doi.org/10.14423/smj.0000000000000214 Narayan, K. M. V., Boyle, J. P., Thompson, T. J., Gregg, E. W., & Williamson, D. F. (2007). Effect of BMI on Lifetime Risk for Diabetes in the U.S. Diabetes Care, 30(6), 1562– 1566. https://doi.org/10.2337/dc06-2544 Pem, D., & Jeewon, R. (2015). Fruit and Vegetable Intake: Benefits and Progress of Nutrition Education Interventions- Narrative Review Article. Iranian Journal of Public Health, 44(10), 1309–1321. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644575/ Sahebi, A., Nejati-Zarnaqi, B., Moayedi, S., Yousefi, K., Torres, M., & Golitaleb, M. (2021). The prevalence of anxiety and depression among healthcare workers during the COVID-19 pandemic: An umbrella review of meta-analyses. Progress in Neuro- Psychopharmacology and Biological Psychiatry, 107, 110247. https://doi.org/10.1016/j.pnpbp.2021.110247 Vegetables | MyPlate. (2020). Myplate.gov. https://www.myplate.gov/eat-healthy/vegetables This study source was downloaded by 100000783599662 from CourseHero.com on 08-30-2021 23:24:09 GMT -05:00 https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m Powered by TCPDF (www.tcpdf.org) https://www.coursehero.com/file/99809470/Health-History-wk-1docx/ http://www.tcpdf.org 1 Well Child Soap USU Physical Assessment MSN 572 January 10, 2021 2 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 3 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. 4 -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. 5 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. 6 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) 7 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 8 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: http://health.gov/dietaryguidelines/2015/guidelines/ 9 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 10 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. https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html 1 Well Child Soap USU Physical Assessment MSN 572 January 10, 2021 2 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 3 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. 4 -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. 5 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. 6 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) 7 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 8 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: http://health.gov/dietaryguidelines/2015/guidelines/ 9 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 10 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. https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html