Case Toddler Informant Explained for Students (Easy Guide)
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Original Question
Case Toddler Informant: Mrs. Faute Patient: Hannah HPI: 3-year-old female here for office visit for well child, mother is concerned because she is having a lot of temper tantrums and when she has them she screams and holds her breath until she seems like she might pass out, parents have tried spanking her, putting her to bed early, talking to her and nothing is working, most of the episodes happen when she is out with her mom shopping, when they sit down for dinner after about 30 minutes and when she does not get her own way. Mother states her 8-year-old never acted like this so she is concerned that she may have autism. Mother notes that her nephew has autism so she is worried she has it too Past Medical History: Right otitis media diagnosed 6 days ago at Urgicenter No other significant illnesses Prenatal/Natal: Born @ 40 weeks; NSVD, + prenatal care B.W. 4.2 kg Apgars: 9/9 No complications of delivery Stayed one extra day for ? hyperbilrubinemia which resolved on it’s own Medications: Amoxicillin 7.5 ml (400mg/5ml) twice a day x 10 days (this is day #5) Motrin as needed Immunizations UTD All: NKMA Developmental History Feeding: Eats table food, likes meats & potatoes as per mom Eats 3 meals a day with 2 snacks in between “Has a sweet tooth” according to mom likes: candy, ice cream and cakes “She takes after her father” She loves her bottle, mom states if she tries to use sippy cup she has tantrum, drinks 3 to 4 8-ounce bottles a day, goes to sleep with bottle at nightSleep: Recently has been fighting her morning nap- cries in bed or plays does not sleep Takes 1-2 hour afternoon nap Goes to bed at 7:30 PM but recently has started fighting this which causes tantrums, has been having nightmares several times a week, wakes up screaming and they can’t control or calm her down, wakes up the whole house, mom feels this is also a sign of autism Elimination: + bladder trained at 28 months + bowel trained 2 months ago- but still has accidents (once or twice a week) + BM qod G & D Motor: Sat @ 7 months, pulled to stand @ 9 months, uses crayons well, right handed, walked @ 13 months; kicks ball, , gets self undressed and partially dressed, walks up stairs alternating steps, Social/emotional: plays with other children at times but seems to get frustrated if she cannot have what she wants or has to take turns will get angry and cry; Language: speech 60% understandable to adults, uses 2-word sentences Cognitive understands day vs nighttime, can repeat ‘wheels on bus’ song, identifies 2 colors, follows direction to climb onto table and to get down. Behavioral “Very intense child” as per mom, gets easily frustrated when unsuccessful at a task; throws temper tantrums, when she gets upset or angry will scream and sometimes “Turns blue then drops-out” as per mom, usually recovers after a few minutes- was evaluated in the ER once for these episodes and told “nothing was wrong with her” as per mom, mother states father and grandparents feel that she is spoiled and just fakes these episodes to get attention- grandmother always cries when it happens, mom tries to ignore them because she states ” I don’t want her to get her way all the time.” Mother thinks this is all because she may be autistic Social Environment Lives in two family house with mom (33) y.o., dad (39 y.o), sister – 8 years old and 17 yo step brother (from father’s first marriage), + dog- 1 year old, she sometimes ‘bothers him’ because she is too aggressive with the dog, house was built in 1924, has 5 bedrooms, two bathrooms, occasional cock roaches in kitchen, when 1st moved in had some mice; no peeling paint, live near park , shopping mall down street, gas station at corner, maternal grandparents live in 2nd section of house, provide babysitting when needed, family is close with grandparents and see them daily Father is a construction worker in the city; mother works in local bakery part time Grandparents or old brother baby-sit when needed Family has health insurance; denies any significant financial problems ROS: General: 3 yo generally healthy female, diagnosed with otitis media at urgent center last week but otherwise doing well, no fevers or recent injuries Skin: denies any rashes, lesions or scars HEENT: Head: No c/o headache Eyes: denies eye discharge, excessive tearing or itching, Ear: diagnoses recently with right ear infection- was crying and had fever at that time, has improved since started antibiotics Nose: + runny nose x 5 days, occasional nose bleeds after she picks her nose Mouth/throat: denies difficulty swallowing or sore throat, + brushes her teeth at night but fights mom at times, has not had dental visit in her life yet Chest: Denies cough or shortness of breath Heart: Denies hx of murmurs, able to run and play and keep up with other children her age Abdomen Mom states she occasionally has constipation which they treat with Miralax, 2 months ago but some days will refuse to go and holds her stool in for a few days & then will have accidents as per mother she feels like she ‘does it on purpose’, fights with them when they try to make her eat vegetables- will throw temper tantrum, denies any vomiting or diarrhea GU: Denies dysuria, + urine trained at 28 months, occasionally has day time accidents when she is playing and forgets to tell her mother MS: Able to run and play, mom states she is pigeon toed and sometimes trips over her own feet Neruo As noted by mother concerned about behavior and frequent temper tantrums and concern for autism Physical Exam: Vitals: Temp 97.8 HR 100 RR 24 B/P 100/58 HT 86.4 CM Wt: 14.5 KG General: Alert well appearing 3-year-old female, sucking on pacifier Skin: Pink, warm, moist, no rashes or lesions noted HEENT Head: NCAT, no hair loss, face symmetrical Eyes – d/c, + tears, sclera clear, PERRLA, discs visualized with no papaledema, Ears: LTM- occluded by cerumen- removal attempted x 3 with no success RTM: slight erythema, + light reflex, mobile, + landmarks Nose: + clear nasal d/c, + small amount dried blood left nares Throat: mucous membranes moist, tonsils +1 no erythema, uvula midline, 20 primary teeth present with + yellowing and decay to central and lateral upper & lower incisors. Neck: supple, + submental nodes palpable Chest: Lungs clear to auscultation bilaterally with no rales, wheezing Heart: HRR, S1 normal, S2 split, no murmurs Abdomen: Soft non distended, with + bowel sounds, no masses, no pain on palpation GU: Tanner l female genitalia Neuromuscular: Alter & active 3 year old, playful in room at times, moving all extremities freely, PERRLA, reflexes 2+ to all extremities, walks well, climbs up on chair, Developmental: Cognitive: follows directions at times, other times is running and jumping on and off table, when mother tries to pick her up kicks at mother and runs away. Gross/fine Motor: Walks well with mild intoeing, climbs on and off exam table by herself, grasps pen well & scribbles, does not copy circle or draw straight line when asked to or shown does not follow directions or attempt to Language Working up the differentials & treatment for each differential Physical exam Concerns? Diagnoses Labs/tests Treatment plan for diagnosis Medications Education referrals Well Child Visit Immunizations To be given today Screening/tests To be done based on this visit Anticipatory guidance Developmental assessment Social & emotional Language Cognitive Gross motor/fine motor Nutrition Sleep Elimination Safety/injury Social Determinants of health Referrals Follow up visits
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