Initial Visit- Meet the Family Part One (graded)

Background and Visit One

Background:

Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Jo-age 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather: Tom-age 62.

Setting: Rural U.S.

Office: Rural, NP owned, Family Practice Clinic

Part One: Today is a busy day in your rural family practice clinic. You are reviewing the chart of your next appointments and realize that there is very little information and that you are scheduled to do a well-woman and two well-child exams for the same family. Your office schedules 20 minutes each for well exams. Upon entering the room, you note a Latino-looking woman who appears in her 40s who sits focused on paperwork, a male toddler climbing on the exam table to reach up and take the otoscope off of the wall, while a preschool-aged appearing female is sitting at your computer pretending to type on the keyboard.

 

As you introduce yourself, the mother stands abruptly and grabs the toddler off of the exam table, smacking his hand and causing him to cry, while simultaneously yelling “I told you to stop it!” She states, “I am so sorry. They usually behave. I am Kayla Field, and this is Riley and Jo.” You then inquire as to the reason for their visit, as you always do. The mother reports they recently moved to the area to live with her parents due to a recent separation from her husband, and she is there to have a physical exams before they lose her husband’s health insurance benefits. She reports that the children are currently healthy and have a regular pediatrician back at home.   She also has a teenage daughter that refused to come today because she wanted to ‘hang out with friends’.

 

The mother reports she would really like to get her well exam done today as she will lose her insurance soon as well with the impending divorce.

 

KAYLA

 

HPI: Kayla reports that she is healthy and takes no medication. She has no symptoms that she can think of other than she is currently having trouble falling and staying asleep, but associates this with stress and with sleeping in the same room with her two younger children. She is a 15 year smoker of 1PPD up until 18 months ago when she quit with the pregnancy of Riley. She is concerned about finances today and reports ongoing fatigue. She has not and menses since the birth of her last child. She is not currently sexually active with men, women, or both and has been abstinent for the last 6 months.

 

PMH: Kayla denies any surgeries or past medical history other than four pregnancies, three births, one pre-term, and two C-sections with the last two births. She had one miscarriage at 10 weeks when she was 16. She also reports that she had PCOS as a teenager and has always had irregular menses. She had gestational diabetes with the last birth and preeclampsia causing the early delivery of Riley. She has no allergies. She is currently taking Advil PM every night to sleep and drinking a glass of wine. She does not routinely exercise. She often skips breakfast and lunch and eats whatever the children eat for dinner, which is often processed, or quick food.

 

CHILDREN

HPI: The mother denies any recent illnesses in either child and reports they are here for their check-up. She does report that since moving in with her parents recently, it has been difficult to get the children to go to bed at night and stay in bed and expresses extreme frustration with this. She reports that they are eating three meals per day and two snacks, one at bedtime and one in the afternoon between lunch and dinner. They do brush their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home. She also verbalizes extreme concern of their impending loss of health insurance.

 

PMH: Jo: Full-term gestation, born cesarean section, weight. 7lb 4 oz. There were no complications in pregnancy, but the mother did smoke 1 pack-per-day throughout pregnancy. There were no hospitalizations—NKDA. The daily medication was chewable children’s multivitamin with iron. They eat three meals and two snacks. There is a great deal of juice, soda, and processed or quick foods given in the house.

Riley: Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother and sometimes takes Cetrizine syrup half a teaspoon once daily, PRN congestion, and a children’s chewable multivitamin daily.

Immunizations:

Jo – Birth – Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months - DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A

 

Riley - Birth – Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months - DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV, Hep B

 

Social History: Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo will be starting kindergarten this fall in the community’s elementary school.

 

Family History: They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago.  The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

 

Discussion Questions Part One:

 

Please prepare yourself to complete the well-woman exam and one of the well-child exams of your choosing.

Per patient- give additional HPI information and questions you would like as well as PMH, Family History, and ROS.  Begin to lay out the objective portion of your note for each patient.

What is your differential diagnosis list for this visit thus far with rational for each of your two patients?

For the child you choose, please list all of the appropriate anticipatory guidance that should be done at a well visit for that age. Expand on one of the topics from your list and provide the education you would offer with citations.

 

 DISCUSSIONS

Discussion Part Two (graded)

 

Physical Examination Jo:

 

Vital signs:  Height: 110 cm, Weight: 27 kg, B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99%

 

General: Cooperative, talkative, appropriate; HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; fundoscopic exam unremarkable; vision by snellen exam 20/40 in each eye, 20/30 together; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil.

 

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal., intact bil  radial and pedal; GU – labia majora and minora intact, no erythema or discharge.

 

Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on right leg but not left with any balance, tries but tumbles; able to balance on each leg for 10 seconds.

 

Cognitive Development: Able to state name and age; can write her own name; able to recall three friends names; knows all colors and can count to 13; dresses herself and has control of bowels and bladder; verbal throughout exam; all of speech clear and recognizable.

 

Physical Examination Riley:

 

V/S: Height: 83cm, HC: 48cm, Weight: 12.3 kg, B/P: 88/52, T: 98.6, HR: 112 BMP/reg., Resp: 24, reg, non-labored, SpO2: 97%

 

General: Active and cries throughout exam; fights being held for exam; calms quickly once exam is over.  HEENT: Head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjuctiva clear, non-icteric, PERRL; unable to complete fundoscopic exam; tympanic membranes intact with scant clear fluid posteriorly bil; EAC unremarkable; pinna/tragus w/o tenderness; nares patent, mucosa pale, sl. edema in inferior and medial turbinates bil, scant clear rhinorrhea; pharynx with mild posterior cobblestoning, tonsils 2/4 bil; primary tooth eruption to include all incisors, canines, and first molars on the lower, upper incisors and first molars; no loose teeth; some yellow discoloration noted to top left central incisor; oral exam unremarkable; neck supple with mild anterior cervical lymphadenopathy bil; thyroid small, firm, equal bil.

 

Cardiopulmonary: heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly;  peripheral pulses reg., equal, intact bil radial and pedal;  GU—both testes present.

 

Musculoskeletal: MAE; able to run in the room and climb on the exam table.

 

Cognitive Development: verbalizes five words: mama, dada, drink, juice, and no; does babble; majority of speech unintelligible; able to feed self; not potty trained.

 

Physical Exam Kayla:

 

Vital signs: Height: 155cm, Weight: 65.5 kg. B/P: 130/76, HR: 82, T: 98.7, Resp: 16, SpO2: 97%

 

General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam; skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy.

 

Cardiopulmonary: heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.

 

Breast Exam: breasts of normal development bil. Areola unremarkable. Nipples without discharge or tenderness. No masses or tenderness upon palpation

 

Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal

 

External Genitalia: mons intact with normal hair distribution, labia majora, minora, clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen.

 

Vagina: pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or discharge.

 

Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile without tenderness.    

 

Uterus: retrograde, small firm, midline, smooth, mobile, non-tender uterus. , size, consistency, mobility. Adnexae: present, smooth, non-tender.

 

Urinalysis in the office: cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and leukoesterase; negative for RBCs, glucose, and ketones.

 

Discussion Questions Part Two:

 

For the patients you have chosen what are your primary and secondary diagnoses now with ICD-10 codes with rationale?

What other diagnostics, preventive screenings, or preventive health actions are you considering for your patients at this time and why?

* Remember to include your evidenced-based reference for your rationale and each step of your plan.

 

Since this visit is a well-child visit, please pick one area of anticipatory guidance appropriate for either Jo or Riley. Be sure to go in and read others posts. Cite all sources of information. List the following with clear headers:

 

Topic

 

Definition

 

Target age range

 

Educational points to be made to the parent concerning this area