EPISODIC SOAP NOTE
Initials: T. S. Age: 11 Sex: Male Race: Caucasian
SUBJECTIVE:
Chief Complaint: 11-year-old well-child examination & follow up for medication change
History of Present Illness: An 11- year-old Caucasian male presents to the
clinic today for his annual well-child examination and a follow up for
tolerance to a medication dose change. Approximately a little over one
month ago, the patient’s mother noticed the development of random
“jerking movements” after an increase in his daily dose of his Daytrana
patch, for which is uses to control his ADHD. During that visit, the nurse
practitioner observed tics as well and decreased his dose to minimize this
side effect. Since the decrease in the dosage, the patient’s mother has not
observed but a few tics in the past month. She feels this medication is
working wonders for him at this dose and does not have any current
concerns with his condition or the
overall health of her son.


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Current Medications:
Wellbutrin 100mg per day for depression
Abreva 2g five times daily as needed for cold sores
Daytrana 10mg/9hr (1 patch) daily for ADHD
Allergies: No known allergies to any medications/foods
Past Medical History: Ultrasounds in utero were normal without any noted
developmental defects. Unremarkable gestational history; he was full term,
39 weeks and 2 days, spontaneous vaginal delivery; he weighed 7 pounds 13
ounces; was discharged 2 days after deliver but his mother remained in the
hospital for 5 days. During delivery, she was drastically torn and began to
hemorrhage. At birth he was found to have a profound hearing loss. He spoke
2 words at 12 months of age, no functional words by age 2 but was able to

gesture what he wanted. At 2 years of age he was evaluated for that hearing
loss and was approved for cochlear implants (for which they couldn’t do for
him). He has since been diagnosed with ADHD, Autism Spectrum Disorder
(fully functioning), and a tic disorder. He has had no hospitalizations except
for at birth; his surgical history includes the attempted cochlear implants and
trigger finger repair. He was seen by Birth
to Three (Early Learning Program), Speech/Language Pathologist and an
Audiologist. He uses sign language in conjunction with speech to
communicate his needs.
Personal/Social History: T.S. was born in West Virginia in 2007 and is the
oldest of 3 children. He lives with his parents and two younger siblings in a
ranch style home in the suburbs of town. His parents are married and have a
healthy relationship. The family has 2 dogs who do not reside within the
home but are up to date on all their vaccinations. Parents do not smoke and
use electric to heat their home. He attends school along with his sister and
does not have any behavioral issues; mom stays home and cares for his
younger autistic brother and dad works out of the home. Mother denies any
recent exposure to any individuals who have been ill or had a
known illness.
Immunizations:

  • Hepatitis A – (8/1/2008, 4/16/2009)
  • Hepatitis B – (4/10/2007, 6/19/2007, 10/17/2007)
  • Diptheria, tetanus and acellular pertussis (DTaP) – (6/19/2007,
    8/21/2007, 10/17/2007, 8/1/2008, 9/30/2011, 6/4/2018)
  • Haemophilus influenza type B (HIB) – (6/19/2007, 8/21/2007,
    10/17/2007)
  • Inactivated poliovirus (IPV) – 6/19/2007, 8/21/2007, 10/17/2007,
    9/30/2011)
  • Influenza (10/17/2007, 11/19/2007, 10/28/2008, 9/30/2011)
  • Influenza (TRIVALENT VACCINE) – (10/29/2010)
  • Measles, Mumps, Rubella (MMR) – (4/16/2008, 9/30/2011)
  • Pneumococcal (PCV7) – (6/19/2007, 8/21/2007, 10/17/2007, 4/16/2008)
  • Pneumococcal (PCV13) – (4/29/2011)
  • Rotavirus Pentavalent – (6/19/2007, 8/21/2007, 10/17/2007)
  • Varicella – (4/16/2008, 9/30/2011)
    Family History: Mother, 34yo female, non-smoker who has no known
    medical history; Father, 37yo male, non-smoker who has no known medical
    history; one brother who has Autism Spectrum Disorder, and a sister with no
    known medical history. Maternal uncles (2) with Autism Spectrum Disorder;
    Maternal and Paternal grandparents, mom unsure of medical history.
    Review of Systems:
    General: Patient alert and oriented x 3, calm, cooperative, and interactive
    with sister and mother in the exam room. Mother/patient report no
    unexplained weight loss or gain, no decreased appetite, no fever or
    noticeable fatigue.
    HEENT: No presence of drainage or redness, patient is deaf bilaterally and
    wears hearing aids; no reports of pulling at ears, no congestion, rhinorrhea,
    sore throat, or hoarseness; no seasonal allergies; last dental exam 6 months
    ago.
    Integumentary: Patient denies changes in skin such as rashes, dryness or
    itching
    Respiratory: Patient denies history of respiratory illness, no reports of SOB at
    rest or with activity; no wheezing.
    Cardiovascular: Denies history of cardiovascular illness or issues
    Gastrointestinal: Patient denies any recent GI illness, no reports of nausea,
    vomiting, or diarrhea. Bowel habits are normal in occurrence/appearance
    Genitourinary: Patient denies any history of GU issues, no itching or
    burning with urination

    Reproductive: Patient has begun to hit puberty
    Musculoskeletal: No history of disease or injuries; moves all extremities
    well, appropriate tone
    Neurological: Patient denies any dizziness or LOC. Moves all extremities
    without tremors; occasional involuntary tics.
    Psychiatric: Patient expresses no thoughts of self-harm or depression;
    interacts well with siblings; No social or mental concerns related with home;
    patient expresses that he rests around 6-8 hours out of every night,
    continuous; about to communicate appropriately.
    Heme/Lymph: Patient denies any issues
    Allergic/Immunologic: No known immune issues or allergies
    OBJECTIVE:
    Vital Signs: Blood pressure 90/62 manually, left arm, standing position;
    Pulse rate 109 and regular; temperature 98.6 tympanic, respirations 18, nonlabored; Height: 51in / 129.54cm;
    Weight: 68lbs / 30.8kg; BMI: 17.68
    General: Well-nourished, alert, healthy male, no apparent distress;
    Interacting suitably with mother, sister and medical staff.
    HEENT: Head is normocephalic; No craniofacial variations from the norm;
    PERRLA; EOM unblemished; Conjunctiva are clear and pale without edema;
    Hearing aids present in bilateral ears, canals are patent; TM nonerythematous, non-swelling in appearance respectively; nares are patent
    without rhinorrhea; Oral mucosa is moist, no lesions, ideal oral cleanliness
    without dental issues; hard and soft palate are without evident contortion or
    injury; Posterior pharynx is clear in appearance; suitable measure of saliva
    noted to guarantee satisfactory hydration.

    Neck: Delicate, supple, without discernable lymphadenopathy; No bulges or
    zones of delicacy upon palpation.
    Integumentary: Skin pink, warm and dry, angular cheilitis, no rashes or
    lesions.
    Respiratory: Lung sounds clear reciprocally in all fields with normal,
    unlabored respiratory rate; No extrinsic sounds noted upon auscultation.
    Cardiovascular: Normal rate and rhythm without murmur, rub or gallop;
    normal pulses at 2+
    Abdomen: soft, and non-distended; no tenderness upon palpation;
    normoactive sounds in every one of the four quadrants.
    Genitourinary/Reproductive: Pubescent male; No indications of injury or
    disturbance to regenerative organs, no hernias noted on palpation
    Musculoskeletal: Patient moves all extremities well; full ROM, good tone,
    no involuntary tics noted at this time.
    Psychological: Patient speaks effectively with good comprehensible
    speech/flow. Good concentration; patient able to follow commands during
    examination, no signs of depression or anxiety.
    Neurological: Patient is alert and oriented x3; able to follow commands;
    normal gait; normal tone throughout
    ASSESSMENT:
    Diagnostics: No diagnostic evaluations were needed or performed during
    this examination.
    Primary Diagnosis:
  • Healthy, well child with new onset tic disorder- Child health is a
    condition of physical, mental, intellectual, social and emotional
    prosperity and not truly the nonappearance of malady or health
    problem (National Research Council, 2004).
    Positive Findings: Involuntary tics
    Negative Findings: Assessment areas normal for age
    Differential Diagnoses:
  • Tourette Syndrome – Tourette Syndrome is an ailment characterized
    by tics. It usually begins in childhood and frequently improves later in
    life. Tics are best portrayed as deliberate actions made automatically
    so that volition is no longer more often than not appreciated. There is
    often an urge, every so often in the shape of a unique sensory feeling
    (sensory tic), that precedes the tic (Hallett, 2015). Tourette Syndrome
    influences young men more than young ladies and is related to
    attention deficit hyperactivity disorder and obsessive-compulsive
    disorder.
    Positive Findings: Tics present, ADHD diagnosis
    Negative Findings: Tics did not begin until introduction of new
    dose of medication and have almost completely subsided since
    the decrease in medication dose.
  • Dystonia – Dystonia is a development issue, portrayed by supported
    or discontinuous muscle contractions causing unusual, frequently
    repetitive, movements, stances, or both. Dystonia can be brought
    about by a wide scope of issues influencing the sensory system and
    may exist either as a secluded variation from the norm or as one piece
    of an increasingly complex motor issue (Lumsden, 2018). Dystonia
    isn’t an ailment all by itself, but instead a side effect of an anomalous
    functioning motor system.
    Positive Findings: Intermittent, unusual muscular movements
    (tics)
    Negative Findings: Tics have decreased with change in
    medication dose

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  • Tremor – is characterized as a cadenced, generally symmetric,
    forward and backward or wavering automatic movement about a joint
    pivot point (Toreres-Russotto, 2019). The reasons for tremors
    incorporate innate disorders (essential tremor), metabolic causes
    (hyperthyroidism, electrolyte variations from the norm), degenerative
    ailments (Wilson’s disease), central lesions (rubral tremor),

    medications (e.g., valproic acid), and psychogenic tremor. (Badheka,
    Barad, & Sankhla, 2018). Children with cerebral paralysis can have
    blended tremors with activity and dystonic highlights.
    Positive Findings: Involuntary tics
    Negative Findings: Patient’s tics are not rhythmic in nature
    Diagnosis/Patient Problems:
  • Well-child
  • Tic Disorder
  • Attention Deficit Hyperactivity Disorder
  • Autism Spectrum Disorder
    PLAN:
    Parent & Patient Education: Patient and patient’s mother was educated
    on the importance of being very observant for the next few weeks and
    reporting any change in frequency or intensity of the tics. The patch is to
    only stay on for 9 hours a day; no longer.
    Anticipatory Guidance/Health Promotion: This is the age normally
    known as pre-adolescent. Kids ordinarily have an expanded rate of
    development, both physically and emotionally. They are regularly
    exceptionally social, and companions’ opinions are very esteemed.
    Confidence and fearlessness are basic variables amid this timeframe. Make
    certain to commend your child for their accomplishments and help discover
    approaches to complement their qualities. Youngster can be exceptionally
    useful and ought to have greater obligation around the family unit. Puberty
    for young men begin 10-14 years old. This is a decent age to start an open
    line of correspondence in regard to the progressions that youngster can hope
    to experience. While numerous schools regularly have. classes that talk
    about this issue, it is imperative to have an adoring, confiding grown-up that
    the youngster can go to, to examine any inquiries or worries that may
    emerge. Consider getting a book or looking on a site. Go over it together so
    you can be there to decipher and exhort. Encourage routine physical activity

    both to improve a healthy way of life and to have a great time. Sports, for
    example, cycling, swimming, ball, soccer, moving, & high impact exercise are
    incredible for cardiovascular well-being. Go for no less than 20 minutes of
    consistent exercise something like 3 times each week. Extending and getting
    ready to avoid damage and advance adaptability are essential as well. Make
    certain to know about what your child is eating all the time. Dietary patterns
    presently can affect his/her well-being later. Your child should have at least
    one cholesterol and one hemoglobin level during this time period.
    Vaccinations are up to date unless you would like to start the Gardasil series.
    Reflection: My essential decision relied upon this present patient’s
    exhibiting evaluation findings. The positive and negative qualities in
    association with each differential finding similarly as the authoritative
    end were documented with partner references. In case a similar patient
    exhibited for appraisal, I would assess and oversee diagnosing equal to
    what my preceptor accomplished for this patient. It is important that
    we, as clinicians provide preventive care that is far reaching, family
    focused, and formatively important, both for youngsters with more
    serious issues to long-term healthy advancement and for families with
    progressively regulating child-rearing concerns. There are so many
    things that can concern parents and it is up to us to provide them with
    the education that they need. In this particular case, this mother
    brought her child in one month ago due to a change in his normal
    condition. It was up to the provider to determine what was wrong and
    what could be don’t to fix the problem. I didn’t realize that there were
    so many conditions that could cause tics in children. Thankfully this
    case was an easier one to figure out right there in the office, instead of
    long draw out testing or procedures. The issue was traced back to the
    medication and he is now on the road to returning to his norm.

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References

Badheka, R., Narendra, B., & Charulata, S. (2018). Pediatric Movement
Disorders. Neurology of
India, 66; S59-67. 10.4103/0028-3886.226447
Hallett, M. (2014). Tourette Syndrome: Update. Brain and Development,
37(7); 651-655.
https://doi.org/10.1016/j.braindev.2014.11.005
Lumsden, D. E. (2018). The Child with Dystonia. Pediatrics and Child Health,
28(10); 459-467.
https://doi.org/10.1016/j.paed.2018.04.016
Torres-Russotto, D. (2019). Clinical Approach to Tremor in Children.
Parkinsonism &
Related Disorders.
https://doi.org/10.1016/j.parkreldis.2019.03.015