Project: Present Concerns/CC
Title: M. O. Date: 05/21/18
Intercourse: Male Age/DOB/Place of Delivery: eight Y/O /04-20-2010/Miami, Florida
SUBJECTIVE
Historian: Dad
Present Concerns/CC:
“He harm his proper arm.”
Little one Profile: (Sexual Historical past (If acceptable); ADLs (age acceptable); Security Practices; Adjustments in daycare/college/after-school care; Sports activities/bodily exercise; Developmental Hx)
Wholesome, well-nourished youngster. Age acceptable communication and growth. Affected person is within the 2nd grade and doing properly.
HPI: (should embody all elements)
eight 12 months outdated male affected person presenting with Dad with a grievance of harm to proper arm. Dad states that affected person fell right now at college and landed on his proper wrist. The affected person stories that the extremity was iced at college. Dad denies administration of ache remedy.
Drugs: (Listing with cause for med )
None.
PMH:
Allergic reactions: NKDA
Treatment Intolerances: None
Persistent Diseases/Main traumas: None
Hospitalizations/Surgical procedures: None
Immunizations: Up to date
Household Historical past ( Please determine all instant household)
Father alive and properly, mom alive and properly.
Social Historical past Schooling degree, occupational historical past, present residing state of affairs/companion/marital standing, substance use/abuse, ETOH, tobacco, and marijuana. Security standing
He lives with each dad and mom. Dad stories that he sometimes smokes cigars however not within the presence of affected person. Affected person is within the 2nd grade.
ROS
Common
Denies, headache, chills, myalgia.
Cardiovascular
Denies chest ache/discomfort, coronary heart issues
Pores and skin
Denies rash or lesions.
Respiratory
Denies cough, issue respiratory, wheezing.
Eyes
Denies discharge from eye, redness, or ache
Gastrointestinal
Denies belly ache, nausea, vomiting, change in urge for food diarrhea, and constipation.
Ears
Denies ache or discharge
Genitourinary/Gynecological
Denies dysuria or modifications in urinary sample.
Nostril/Mouth/Throat
Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth ache, sore throat, or issue swallowing
Musculoskeletal
Stories harm and ache to left arm
Breast
Denies ache or tenderness
Neurological
Denies lack of consciousness, dizziness, headache, or alteration in psychological standing
Heme/Lymph/Endo
Denies weight reduction, exercise intolerance, warmth or chilly intolerance
Psychiatric
Denies despair, anxiousness, or suicidal ideation
OBJECTIVE (plot top/weight/head circumference together with noting percentiles) Connect progress chart
Weight 30.three kg Temp 98.9 F BP 97/59 mmHg
Peak 50 in
BMI: 18.74
Pulse 100 x’ Resp 20 x’
Sp02
Common Look and dad or mum‐youngster interplay:
No acute misery, well-developed, properly nourished, alert.
Pores and skin
Pores and skin pink, heat, and dry, no rashes or lesions famous.
HEENT
Head normocephalic, nasal mucosa regular, nares patent and clear, no eye discharge, regular conjunctiva bilaterally, moist mucus membranes, tonsils regular, no swelling famous.
Cardiovascular
S1S2 audible. Common charge and rhythm. No murmurs.
Respiratory
Lungs clear, good air alternate, no wheezes or rales
Gastrointestinal
Stomach spherical, mushy, non-tender, and non-distended, regular bowel sounds, no organomegaly
Breast
Deferred
Genitourinary
Bladder is non-distended; no CVA tenderness, exterior and inside genitalia not examined.
Pediatric SOAP Observe
Musculoskeletal
Restricted vary of movement to proper wrist; no swelling, bruising, or apparent deformity famous, robust pulses famous.
Neurological
Alert, strikes all extremities spontaneously
Psychiatric
Age acceptable growth.
In-house Lab Exams – doc checks (outcomes or pending)
Proper wrist x-ray – closed fracture at distal radius
Pediatric/Adolescent Assessment Instruments (Ages & Levels, and so on) with outcomes and rationale
For adolescents (HEADSSSVG Assessment)
Analysis
· 1. Closed fracture of distal finish of proper radius – S69.91XA
· Pertinent positives – stories current harm to left arm, restricted ROM to proper wrist, ache with ROM, fracture indicated on x-ray
· Pertinent negatives – no apparent deformity, no swelling
· Rationale – Restricted ROM following harm or trauma to the arm counsel attainable fracture.
2. Different specified sprain of proper wrist, preliminary encounter – S63.591A
· Pertinent positives – stories current harm to left arm, restricted ROM to proper wrist, ache with ROM
· Pertinent negatives – no apparent deformity, no swelling
· Rationale – Damage to the arm could end in a sprain, dislocation or fracture wrist. Absence of apparent deformity can is favorable of a sprain or dislocation; nevertheless, impaired ROM and affirmation of fracture through x-ray guidelines out analysis of sprain.
three. Dislocation of proper wrist – M24.331
· Pertinent positives – stories current harm to left arm, restricted ROM to proper wrist, ache with ROM
· Pertinent negatives – no apparent deformity, no swelling
· Rationale – Damage to the arm could end in a sprain, dislocation or fracture wrist. Absence of apparent deformity can is favorable of a sprain or dislocation; nevertheless, impaired ROM and affirmation of fracture through x-ray guidelines out analysis of dislocation.
·
· Major diagnoses: Closed fracture of distal finish of proper radius – S69.91XA
PLAN together with training
· Arm splinted with brief arm Ortho-glass and ace wrap, sling utilized for affected person consolation. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)
· Affected person and pop instructed that affected person keep away from participation in PE till cleared by orthopedic, college be aware supplied
· Administer Tylenol or Motrin each Four-6 hours as wanted for ache.
· Comply with-up with Orthopedics, copy of x-ray CD supplied
·
References
Arora, 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
