(SOAP NOTE) NR511 Jo AGE 5 FEMALE (CC
Difficulty to get children to go to bed and stay in bed)
Jo AGE 5 YEARS FEMALE
Subjective
Chief complaint: difficult to get the children to go to bed at night and stay in bed
History of present illness (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. Jo has been
getting up to play in the room at night and 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. Riley is still taking infant formula.
Mother brushes 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.
Past Medical History/Birth history: Full-term gestation, born cesarean section, weight. 7 pounds 4 ounces.
There were no complications in pregnancy, but the mother did smoke 1 pack-per-day throughout pregnancy.
There were no hospitalizations—NKDA
Nutrition: 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.
Immunizations: Birth Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP,
COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV
13, 18 months – DtaP, Hep A
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. Kayla has a history with gestational diabetes. Mary has a history of hyperlipidemia, Type 2 DM, and
Hypertension. Tom 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
but also had PCOS and difficulty conceiving. Other family members died of old age. She is unaware of
paternal familial health history.
Social and environmental history: Both children currently live with their mother and maternal grandparents
for the last 8 weeks. Their father is involved but lives several hours away where he works. Jo will be starting
kindergarten this fall in the community’s elementary school.
Cultural history: They are Latin American in descent, the grandparents emigrated from Cuba in the 1970s. Jo
and Riley are United States soil.
Review of Systems:
Neurologic: Frequent morning headaches? Do you have any developmental concerns? Is she hyperactive
while at school? Any difficulties paying attention? Irritability of mood swings throughout the day?
Head/Eyes/Ears/Nose/Mouth/Throat: Does she have enlarged tonsils? Frequent colds or sore throats?
Frequent ear infections? Changes in vision? Changes in hearing?
Integumentary: Any rashes, reports of itching, change in pigmentation, excessive moisture or dryness,
presence of wounds, presence of invasive devices, alterations in texture, changes in hair growth, texture or
loss, nail changes, tenderness, no swelling
Cardiovascular: cyanosis and dyspnea, heart murmurs, exercise tolerance, squatting, chest pain, palpitations
Respiratory: Does she mouth breath or have trouble breathing through the nose? Asthma?
Genitourinary: Any urgency, frequency of urination at night? Any blood in the urine?
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, Endocrine: Have you noticed excessive weight gain? Or failure to gain weight? Any increase in hunger, thirst,
urination or problems with hot or cold environments?
Gastrointestinal: Does she have difficulty swallowing and/or drooling? Have you had any complaints of
nausea vomiting or stomach acid reflux? Do any of the following occur: changes in appetite, dysphagia, and
indigestion, food intolerances to milk products, abdominal pain, heartburn, denies nausea, denies vomiting,
denies hematemesis, no jaundice, or denies constipation?
Musculoskeletal: Does she sleep walk? Any muscular disorders?
Hematologic: Any prevalent genetic disease? Any bleeding problems in skin; excessive bruising. Exposure to
toxins, any blood transfusions.
Objective
Vital signs: height: 110 centimeters 75th percentile; weight: 29 kilograms, BMI 24.0 (Normal 18.5-25) BMI
percentile is 95% B/P:102/60, T: 98.2, HR: 94 BMP/reg., Resp: 18, reg, nonlabored, 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 bilateral
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. Tanner 1 breasts and pubic area.
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
Assessment
Primary Diagnosis
1. Wellness Child Exam ICD 10: Z00.129. In the wellness child exam the child is screened for
immunization, growth and development, disease prevention and health promotion. Secondary
Diagnosis
2. Obesity ICD (10: E66.1) - Obesity according to the CDC (2017) is equal to or greater than the 95th
percentile of a growth chart. The patient’s current BMI is 24% which places her above the 99th
percentile for girls aged 5.
3. Behavioral insomnia (ICD 10: Z73.811)- Behavioral insomnia of childhood usually presents with
perceived difficulties in initiating or maintaining sleep that require interventions by parents or other
caregivers to overcome them (Ringdahl et al., 2004).
a. This is a potential diagnosis for this patient as the parent states the child gets up to play in the room
at night.
4. Anxiety (F41.1) -Lusk (2015) utilized the psychodynamic theory to describe anxiety as a conflict
between the id and ego. As a direct consequence, aggressive and impulsive drives may be experienced
as unacceptable resulting in repression. These repressed drives may break through repression,
producing automatic anxiety (Lusk, 2015). Cognitive theory has explained anxiety as the tendency to
overestimate the potential for danger (Lusk,
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