Rotation 4 H&Ps

History and Physical

Identifying Data:

Name: JD

Age: 15

Race: Asian

Date & Time: 7/8/2020, 5:30 PM

Location: Pediatric Emergency Department, NYC H+H/Queens Hospital Center

Source of Referral: None

Source of Information: Self/Mother – Reliable

Mode of Transport: Personal vehicle

 

Chief Complaint:

Lump on right leg x 4 days

 

History of Present Illness:

JD is a 15-year-old male with a significant past medical history of MRSA skin abscess on his right lower leg who presents with his mother complaining of a lump on his right lower leg x 4 days. He was seen in the Pediatric ED at QHC in December 2019 for a similar complaint in a site on his right lower leg slightly proximal to the lump he is complaining of today. He was diagnosed with a right lower leg abscess at that visit and a wound culture came back positive for MRSA. He was transferred to Cohen Children’s Hospital for evaluation and treatment by pediatric surgical and infectious disease teams. The abscess was incised and drained and he was treated for the MRSA infection with vancomycin.

Today, he reports that he first noticed the lump on his right lower leg 4 days ago and it has since become significantly swollen and erythematous. Overnight, he reports that he noticed some spontaneous drainage from the wound and his father helped him express purulent material and blood from the wound. Upon waking and through today, he admits that the swelling has not improved and the surrounding erythema has spread, so he presented to the ED for evaluation. He denies pain, fever, chills, known insect/animal bite, rash at another site, a puncture wound or any other break in the skin prior to the onset of symptoms, decreased range of motion in the right lower extremity, impaired weight bearing, sick contacts, recent travel, or any other symptoms.

Past Medical History:

Present illness:

Denies any medical conditions

Past illness:

1. MRSA skin abscess on right lower leg – December, 2019
   1. Wound culture at QHC positive for MRSA
   2. Transferred to Cohen Children’s Hospital for I&D and follow-up with infectious disease specialist
   3. Treated with Vancomycin as per wound culture sensitivities
   4. Healed well, no complications

Hospitalizations:

See above; no other hospitalizations reported

Immunizations:

All immunizations up to date

Past Surgical History:

1. I&D for MRSA skin abscess on lateral aspect of right lower leg – December, 2019
   1. Cohen Children’s Hospital
   2. Healed well, no complications

Denies any other surgeries, injuries, and blood transfusions

Medications:

JD does not take any medications on a daily basis

Allergies:

Denies any known allergies to medications, foods, or environmental factors

Family History:

Non-contributory

Social History:

Habits:

JD denies any tobacco, alcohol, and illicit drug use

Travel:

         JD denies any recent travel

Home:

         JD lives at home with his mother and father

Diet:

         JD eats a balanced diet, but admits to eating more junk food in recent months

Sleep:

         JD typically sleeps for at least 8 hours per night.

Exercise:

         JD is less active than he was prior to quarantine, but admits to at least 30 minutes of activity per day

Safety:

JD uses all appropriate safety measures

Review of Systems:

General:

    Denies fever, chills, fatigue, weakness, and loss of appetite

Skin:

    See HPI

Pulmonary:

    Denies dyspnea, shortness of breath, cough, and wheezing

Cardiovascular:

   Denies chest pain and known heart murmur

Musculoskeletal:

Denies joint pain, swelling, deformity, decreased ROM, or any other abnormalities throughout

Neurological:

Denies loss of sensation, paresthesia, or numbness

Physical Exam:

Vital Signs:

Blood Pressure:

                     122/86, right arm, sitting

Heart Rate:

82 bmp, regular

         Respiration Rate:

                     18 bmp, non-labored

Temperature:

                     98.7 F, oral

O₂ Sat:

                     99%, room air

Height:

                     66 inches

Weight:

                     189 lbs

         BMI:

30.5    

 

General Appearance:

15-year-old male accompanied by his mother. Alert and oriented x 3. Well-groomed with good hygiene. Dressed appropriately. Patient is in no acute distress.

 

Skin:

4 cm raised abscess with approximately 10 cm of surrounding erythema on lateral aspect of right lower leg 8 cm above the right ankle. Central break in the skin without active bleeding or drainage. Nontender to palpation. No appreciable induration or fluctuance over the abscess or surrounding area. Slightly warmer to the touch compared to the opposite leg.

Scar from I&D of abscess 6 months ago on lateral aspect of right lower leg 4 cm below right knee. Healed well.

Skin warm and moist without cyanosis. Capillary refill < 2 seconds throughout

 

Chest:

Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation.

 

Lungs:

Clear to auscultation bilaterally with no adventitious lung sounds.

 

Cardiovascular:

Regular rate and rhythm (RRR); S1 and S2 present without any murmurs, rubs, or gallops.

 

Musculoskeletal:

FROM in upper and lower extremities bilaterally with passive and active motion. No weight bearing limitations or abnormal gait. 5/5 muscle strength in the lower extremities bilaterally. Neurovascular status intact bilaterally

 

Labs:

• CBC
  • WBCs elevated with left shift

 

• Wound culture and sensitivities (not resulted until next day)
  • Positive for MRSA
  • Sensitive to vancomycin, resistant to clindamycin

 

Assessment:

JD is a 15-year-old male with a significant past medical history of MRSA skin abscess on his right lower leg who presents with his mother complaining of a lump on his right lower leg x 4 days. Physical exam and history are consistent with recurrent MRSA skin abscess and cellulitis of the right lower leg.

 

Differential Diagnosis:

1. Skin abscess
2. Cellulitis
3. Erysipelas
4. Necrotizing fasciitis

 

Plan:

1. Recurrent skin abscess and cellulitis of right lower leg, possible MRSA
   1. Transfer to Cohen Children’s Hospital via EMS for further evaluation and treatment by pediatric surgical and infectious disease teams

1. Evaluate for MRSA colonization

1. 1. Treat with 1 dose of Vancomycin 1 gram as per previous culture and sensitivity prior to transfer by EMS by peripheral IV

1. Dose initiated in QHC Pediatric ED – Vancomycin 1 gram in 500 mL NS
   1. Patient reported sudden onset of itchy scalp shortly after initiation, so Vancomycin discontinued
      1. Benadryl 50 mg PO given; patient reported symptom relief

 

History and Physical

Identifying Data:

Name: DSP

Age: 13

Race: Hispanic

Date & Time: 7/8/2020, 11:00 AM

Location: Pediatric Emergency Department, NYC H+H/Queens Hospital Center

Source of Referral: None

Source of Information: Self (questionably reliable) and SCO staff member (reliable)

Mode of Transport: EMS

 

Chief Complaint:

Agitation x 2 hours

 

History of Present Illness:

DSP is a 13-year-old female with a significant past psychiatric history of disruptive mood disorder and major depressive disorder and no significant past medical history who is brought in by EMS/NYPD and SCO staff for a psychiatric evaluation due to agitation x 2 hours. SCO staff member also expressed concern for foreign body ingestion. She has been admitted to multiple facilities for psychiatric evaluation and episodes of agitation in the past as per the SCO staff member but is previously unknown to QHC. She has only been at SCO for the last 3 weeks so the staff member notes that she is relatively new to the facility and is unable to provide much history.

DSP reports (and SCO staff member confirms) that she woke up this morning from a bad dream where her father almost died and was in a bad mood. She then asked the SCO staff member to take her down to the laundry room so she could retrieve a dress but was told she would have to wait until after breakfast. She became extremely agitated when she was not taken immediately. As a result, she ran out of the facility and began vandalizing and stealing from nearby parked vehicles. SCO staff found her shortly after with magnets and pieces of glass, as well as an AA battery in her mouth and brought back inside the facility. NYPD/EMS were called to transport the patient to QHC’s pediatric ED for a psychiatric evaluation and evaluation for potential foreign body ingestion. When NYPD arrived to restrain her, she resisted and hit her head on a chair. She denies having ingested any foreign bodies (battery, magnet, glass), but endorses prior foreign body ingestion (“I swallowed a screw a long time ago”) because they “taste good.” DSP denies any headache, change in vision, nausea, vomiting, diarrhea, constipation, fever, chills, visual or auditory hallucinations, suicidal or homicidal ideations, coughing, SOB, pain, or any other symptoms.

 

Past Medical History:

Present illness:

1. Disruptive mood disorder
   1. Neither patient nor SCO staff member able to provide information on when diagnosis was made or where
   2. Patient receives follow-up through SCO
2. Major depressive disorder
   1. Neither patient nor SCO staff member able to provide information on when diagnosis was made or where

 

1. Patient receives follow-up through SCO

Past illness:

Denies any past illnesses; patient is unknown to QHC so there is no available information in her chart

Hospitalizations:

Patient reports (and SCO staff member confirms) multiple prior presentations to other pediatric EDs for agitation and psychiatric evaluation. DSP is unable to provide further information, but appears to understand the process (asked if she will require a one-to-one).

Immunizations:

All immunizations up to date

 

Past Surgical History:

Denies any surgeries, injuries, and blood transfusions

 

Medications:

1. Aripiprazole (Abilify) 15 mg PO QD nightly
   1. Last dose given last night
2. Lamotrigine (Lamictal) 200 mg PO QD nightly
   1. Last dose given last night
3. Fluoxetine (Prozac) 20 mg QD daily
   1. Last dose given this morning

 

Allergies:

Denies any known allergies to medications, foods, or environmental factors

 

Family History:

Patient unable to provide detailed family history other than that her father is living. SCO staff member reports that she also cannot provide family history because the patient is relatively new to the facility and she does not have access to that information currently.

 

Social History:

Habits:

DSP denies any tobacco, alcohol, and illicit drug use

Travel:

         DSP denies any recent travel, but SCO staff member notes that she only came to the facility 3 weeks ago so she is unaware of other possible travel

Home:

         DSP lives at the SCO facility with many other children and is overseen 24/7 by staff members

Diet:

         DSP eats a balanced diet as per the SCO staff member

Sleep:

         DSP typically sleeps for at least 8 hours per night.

School:

 

 

DSP is going into the 8th grade in the upcoming school year. She reports that she likes school, but did not like it as much this past semester due to the online learning. She reports that her grades are “good.” She enjoys playing with her friends and watching television

Exercise:

         DSP is less active than she was prior to quarantine, but admits to at least 30 minutes of activity per day

Safety:

DSP uses all appropriate safety measures

 

Review of Systems:

General:

Denies fever, chills, fatigue, weakness, and loss of appetite

Skin:

Reports multiple scars on forearms and left hip “from when I cut myself with glass.” Denies any changes in hair pattern or skin texture or new skin lesions

Head:

Reports that she hit her head on a chair earlier today when being restrained. Denies headache, confusion, dizziness, loss of consciousness.

Eyes:

Does not wear corrective lenses or contact lenses. Denies change in vision, eye pain, discharge, crusting, swelling. Does not recall last eye exam.

Ears:

Denies changes in auditory acuity, ear pain, discharge, and foreign body.

Nose:

Denies nasal congestion, rhinorrhea, epistaxis, and foreign body

Mouth/Pharynx:

Denies pain, bleeding gums, sores, sore throat, and change in taste. Reports that she does not like the dentist and cannot provide information about her last dental visit.

Neck:

Denies neck pain and swelling.

Pulmonary:

Denies dyspnea, shortness of breath, cough, and wheezing

Cardiovascular:

Denies chest pain and palpitations.

Gastrointestinal:

Denies food intolerances, changes in bowel habits, nausea, vomiting, constipation, diarrhea, abdominal pain, blood in her stool, or any other symptoms.

Genitourinary:

Denies menarche. Denies dysuria, urinary frequency or urgency, change in color of urine, blood in urine, and abnormal vaginal discharge

Musculoskeletal:

Denies joint pain, swelling, deformity, decreased ROM, or any other abnormalities throughout

Neurological:

Denies loss of sensation, paresthesia, or numbness

Psychiatric:

See HPI. Reports that she feels sad often and has cut herself in the past.

 

 

Physical Exam:

Vital Signs:

Blood Pressure:

                     102/62, right arm, sitting

Heart Rate:

                     80 bpm, regular

Respiration Rate:

                     18 bpm, non-labored

Temperature:

                     98.0 F, oral

O₂ Sat:

                     100%, room air

Height:

                     59 inches

Weight:

                     98 lbs 

         BMI:

19.8    

 

General Appearance:

13-year-old female accompanied by SCO staff member. Alert and oriented x 4. Well-groomed with good hygiene. Dressed appropriately. Patient brought in agitated and restrained initially, but appears calm and cooperative currently for the exam.

Skin:

1.5 cm abrasion on left frontal area due to hitting head on chair. Not actively bleeding and nontender to palpation. Multiple healed transverse scars on forearms bilaterally and 1 scar on left lateral hip.

Skin warm and moist without cyanosis. Capillary refill < 2 seconds throughout

Head:

1.5 cm abrasion on left frontal area due to hitting head on chair. Otherwise normocephalic and atraumatic

Eyes:

PERRLA. Cornea clear, conjunctiva pink, and sclera white. EOMI. Visual fields full.

Ears:

Symmetrical without any observed abnormality. No tenderness to palpation of tragus and manipulation of pinna. TMs pearly-gray with cone of light in appropriate position bilaterally.

Nose:

No abnormality visualized. Nontender to palpation without bogginess or appreciated step-off. Nares patent bilaterally. Septum within normal limits. Nasal mucosa pink. No foreign body visualized.

Mouth/Pharynx:

Mucosa pink and moist. No sores or lesions visualized. Tongue midline. Uvula midline and posterior pharynx rises symmetrically. No foreign body visualized. No evidence of burns or lesions consistent with battery. Pharynx nonedematous without exudates.

Neck:

No swelling or deformity visualized. No cervical lymphadenopathy appreciated. FROM without pain.

Chest:

 

Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation.

Lungs:

Clear to auscultation bilaterally with no adventitious lung sounds.

Cardiovascular:

Regular rate and rhythm (RRR); S1 and S2 present without any murmurs, rubs, or gallops.

Abdomen:

Flat without abnormal bulges or pulsations. BS+ in all 4 quadrants. Soft and nontender to palpation throughout. No masses appreciated.

Musculoskeletal:

FROM in upper and lower extremities bilaterally with passive and active motion. No weight bearing limitations or abnormal gait. 5/5 muscle strength in the upper and lower extremities bilaterally. Neurovascular status intact bilaterally

Neurologic:

Alert and oriented x 4. Cooperative and follows commands.

Mental Status Exam:

Normal affect with slightly labile mood. Appropriate eye contact. Becomes upset easily but is easily calmed. Speech is normal with normal rate, volume, and rhythm. No suicidal or homicidal ideations.

 

Labs:

• CBC
  • WNL
• CMP
  • Alkphos elevated to 231 U/L
  • Total protein decreased to 6.5 g/dL
• Acetaminophen level
  • WNL
• Salicylate level
  • WNL
• Urine pregnancy
  • Negative

 

Imaging:

• X-Ray soft tissue, neck
  • No radiopaque foreign body is seen. The prevertebral soft tissues are normal. The laryngeal and tracheal air columns are normal. There is suggestion of vertebral anomaly involving C4 and C5. Cervical spine radiograph recommended if clinically warranted.
• X-ray cervical spine
  • Reversal of normal lordosis localized at the C5 level with vertebral body deformities involving C4 through C7. Congenital fusion of C2 and C3. Soft tissues are normal. CT or MRI would be recommended to further delineate spinal abnormalities.
• X-Ray of chest
  • Normal chest
• X-Ray of abdomen
  • No radiopaque foreign body seen

 

Assessment:

DSP is a 13-year-old female with a significant past psychiatric history of disruptive mood disorder and major depressive disorder and no significant past medical history who is brought in by EMS/NYPD and SCO staff for a psychiatric evaluation due to agitation x 2 hours. Radiographs are negative for foreign body ingestion. Patient is medically cleared and referred to psychiatry for evaluation of agitation and exacerbation of disruptive mood disorder

 

Plan:

• Disruptive mood disorder/agitation
  • Psychiatric and social work consults called for evaluation
    • Patient and SCO staff member interviewed separately
  • Continue existing medications as directed
  • One-to-one observation
  • Overnight observation and re-evaluation in the morning
    • Patient was calm and cooperative in the morning
    • Not a threat to herself or others
      • Discharged back to SCO facility with instructions to follow up with psychiatrist and therapy
    • Patient counselled on behavior, following rules, and how to redirect her anger
  • Major depressive disorder
    • Psychiatric and social work consults called for evaluation
      • Patient denied suicidal ideations
    • Continue existing medications as directed
    • Discharged back to SCO facility with instructions to follow up with psychiatrist and therapy
  • Possible foreign body ingestion
    • Radiographs negative for foreign body
    • Patient counselled on importance of not ingesting non-food items
  • Return to the pediatric ED for evaluation for future episodes of agitation or if patient develops fever, ingests foreign body, develops stridor, or any other symptoms
  • SCO staff instructed to monitor patient closely due to history of self harm

 

SOAP Note

Identifying Data:

Name: AS

Age: 7 days

Race: Asian

Date & Time: 7/22/2020, 12:00 PM

Location: Neonatal Intensive Care Unit, NYC H+H/Queens Hospital Center

Source of Referral: None

Source of Information: None

Mode of Transport: None

 

S:

AS is a 7-day-old female with a significant past medical history of Monosomy X mosaic type as per chromosomal analysis and neonatal hyperbilirubinemia delivered at 36 3/7 weeks via Cesarean section was admitted to the NICU at delivery due to extremely low birth weight ( 3 lbs 7.7 oz), respiratory distress, and prematurity. Her mother is a 26-year-old G4P1122 female who was induced for an emergency Cesarean section due to Category II fetal heart tracing and intrauterine growth restriction affecting the care of the mother following a full course of antenatal steroids. APGAR scores were 9 and 9 at 1 and 5 minutes. NIPT at 28 weeks gestation resulted positive aneuploidy consistent with a single X chromosome and no detectable Y chromosome consistent with Monosomy X. Parents declined amniocentesis. Features are inconsistent with Monosomy X, so mosaic type is suspected and confirmative postnatal serum chromosome analysis was performed confirming the variant. Her hospital course was complicated by respiratory distress at birth, for which she was briefly placed on CPAP with an FiO2 of 30% and PEEP of 5 for a total of 5 hours. She was taken off CPAP when she appeared stable and has been saturating well on room air and is in no distress. She also had a mildly elevated HSV IgM at birth, for which an ophthalmology consultation was ordered to rule out chorioretinitis.

Today, AS’s mother reports that she noticed a rash on her backside while her assigned nurse was cleaning and changing AS and is concerned that there was some blood visible. AS appears comfortable and in no distress. She has been afebrile and tested negative for COVID-19 on 7/16/2020. She is fed only breast milk by mouth and produces stool after every feeding (Q1-2 hours).

 

PMHx:

1. Monosomy X, mosaic type
2. Hyperbilirubinemia of the newborn
3. Small for gestational age secondary to IUGR
4. Mildly elevated HSV IgM at birth

PSHx:

No past surgeries, injuries, or blood transfusions

Allergies:

No known allergies to medications, foods, or environmental factors

Medications:

No current medications

FHx:

 

 

• Mother – PTSD, OCD, Major Depressive Disorder with intentional self harm, HSV-2 (not acutely at time of delivery)
  • Denies history of HTN, T2DM, HLD, heart disease, cancer, or any other medical conditions
• Father – Denies history of HTN, T2DM, HLD, heart disease, cancer, or any other medical conditions
• Maternal grandmother – living; history of leukemia
  • Denies history of HTN, T2DM, HLD, heart disease, or any other medical conditions
• Maternal grandfather – HTN, HLD
  • Denies history of T2DM, heart disease, cancer, or any other medical conditions
• AS’s mother unable to provide information about paternal grandparents

 

O:

Vitals:

Temperature: 98.3 F, axillary

HR: 152 bpm, regular

BP: 74/51, left arm; supine

RR: 41 bpm

SpO2: 100%, room air

Length: 18.5 inches

Weight: 3 lbs 8.8 oz (+1.1 oz from birth)

 

Physical Exam:

General:

7-day old female small for gestational age; well-appearing, alert and active late preterm newborn in heated isolette for thermoregulation. Good cry and easily consoled. In no acute distress.

Head:

Microcephalic; sutures within normal limits and fontanelles open and flat. Atraumatic.

Skin:

Skin is warm and well-perfused throughout. Skin is pink without cyanosis or jaundice. Capillary refill <2 seconds throughout. Significant perianal erythema with some satellite lesions noted. Not currently bleeding, but skin appears broken in some spots and friable. Skin folds spared.

Eyes:

Sclerae white, conjunctiva pink, corneas clear. PERRL.

Ears:

Well-formed and symmetrical pinnas in appropriate position inconsistent with typical Monosomy X presentation.

Nose:

No visible deformity; No bogginess on palpation without step-off. Nares patent bilaterally without discharge.

Mouth/Pharynx:

 

No visible lesions externally or internally. Palette closed without deformity. Unremarkable.

Neck:

Supple without palpable masses. Clavicles intact bilaterally. FROM. No webbing visualized.

Lungs:

Chest unremarkable upon examination with appropriately spaced nipples. Respirations appear unlabored without chest heaving, contractions, or nasal flaring. Lungs clear to auscultation bilaterally without adventitious lung sounds or tachypnea.

Heart:

No visible abnormal pulsations or heaves. PMI in appropriate position. RRR; S1 and S2 present without murmurs, rubs, or gallops. On continuous cardiac monitoring.

Abdomen:

Normal appearance without distension. BS+ in all 4 quadrants. Soft and nontender without palpable organomegaly or masses. Umbilical stump drying and healing well.

Genitourinary:

Normal female newborn.

Musculoskeletal:

No visible deformity and extremities nonedematous. Symmetrical leg length with symmetrical thigh and gluteal folds.

Neurologic:

Easily aroused. Good symmetrical tone and strength. Spine unremarkable. Positive newborn reflexes (grasp, suck, Moro, Babinski)

 

Labs:

CBC (7/17/2020):

WNL

Total Bilirubin:

7.1 mg/dL (7/22/2020), 6.9 mg/dL (7/21/2020), 10.2 mg/dL (7/20/2020), 8.7 mg/dL (7/19/2020), 5.4 mg/dL (7/18/2020), 6.8 mg/dL (7/17/2020), 5.6 mg/dL (7/15/2020)

CMP (7/17/2020):

WNL

Chromosome analysis:

Abnormal female karyotype, variant mosaic Turner Syndrome

Karyotype: mos 45, X [11], 46, X, r (X) (p22, q?26) [9]

COVID-19 PCR (7/16/2020):

Not detected

Cytomegalovirus PCR, urine (7/16/2020):

Not detected

 

Imaging:

Renal ultrasound:

Performed due to suspected Monosomy X. The kidneys are normal in configuration without evidence of hydronephrosis.

Head ultrasound:

Performed due to microcephaly. No significant abnormality seen.

 

Echocardiogram:

Performed due to prematurity and suspected Monosomy X. No abnormality visualized.

 

A:

AS is a 7-day-old female with a significant past medical history of Monosomy X mosaic type as per chromosomal analysis and neonatal hyperbilirubinemia delivered at 36 3/7 weeks via Cesarean section was admitted to the NICU at delivery due to extremely low birth weight ( 3 lbs 7.7 oz), respiratory distress, and prematurity. Physical exam findings are consistent with candidal diaper dermatitis.

 

P:

1. Candidal diaper dermatitis
   1. Nystatin (Mycostatin) powder 100,000 U/g – 1 application Q6 hours x 7 days
   2. Zinc oxide (Desitin) 40% ointment – 1 application Q3 hours x 7 days (with each diaper change)
   3. Leave bottom open to air to facilitate healing
2. Neonatal hyperbilirubinemia
   1. B+, Coombs negative
   2. S/p phototherapy 7/16/2020 – 7/18/2020
   3. Monitor bilirubin levels daily
   4. Monitor CBC weekly with differentials and reticulocytes
   5. Monitor for jaundice
3. Monosomy X, mosaic variant
   1. Consult pediatric geneticist
4. Small for gestational age
   1. Monitor intake and output
   2. Daily weight
   3. Continue feeding regimen and monitor feeding tolerance
   4. Encourage breastfeeding and skin-to-skin contact
5. Elevated HSV IgM
   1. Ophthalmology consultation to rule out chorioretinitis
      1. Eye exam normal without chorioretinal scars bilaterally  (7/22/2020) via dilated fundus exam
6. Continue on room air
   1. Monitor for signs of respiratory distress
7. Follow-up CMV urine PCR
8. Continue cardiac monitoring

 

History and Physical

 

Identifying Data:

Name: OO

Age: 15

Race: Black

Date & Time: 7/15/2020, 9:00 AM

Location: Pediatric Clinic – Endocrinology, NYC H+H/Queens Hospital Center

Source of Referral: QHC Pediatric Emergency Department

Source of Information: Self and mother

Mode of Transport: Personal vehicle

 

Chief Complaint:

Elevated HgbA1c and FSG x 5 days

 

History of Present Illness:

OO is a 15-year-old female with a significant past medical history of Class 3 obesity (BMI 51.6) presents to the clinic with her mother via referral from the Pediatric ED at QHC for evaluation of an elevated HgbA1c level. OO presented to the Pediatric ED on 7/10/2020 after referral to the ED by her PCP due to elevated HgbA1c level (12.8%) and fasting blood glucose (350 mg/dL) as part of her routine labs for her yearly physical. Her finger-stick glucose in the ED was 375 mg/dL. She reported no symptoms or sick contacts at the time of her visit. The ED provider prescribed metformin 500 mg QD in the evening and referred her to the endocrinologist in the pediatric clinic. She reports that she was unable to pick up the metformin from the pharmacy because the ED provider prescribed a brand name and it was too expensive, so she has been taking her mother’s medication. She reports no tolerance issues.

Today, OO has no complaints but reports that she is feeling nervous. Her mother admits to a strong maternal family history of Type 2 Diabetes Mellitus. OO’s mother reports (and OO agrees) that she started noticing recently that OO has been drinking significantly more water than previously and has been urinating more frequently, noting that she sometimes wakes up during the night to urinate. She denies polyphagia, recent unintentional weight loss or gain, heat or cold intolerance, neck pain or swelling, fever, chills, nausea, vomiting, diarrhea, constipation, sick contacts, chest pain, SOB, coughing, palpitations, lower extremity edema, or any other symptoms.

 

Past Medical History:

Present illness:

Class 3 obesity – “always had issues with weight”

BMI 51.6

Past illness:

Denies any past illnesses

Hospitalizations:

Denies any hospitalizations

Immunizations:

All immunizations up to date

 

Past Surgical History:

Denies any surgeries, injuries, and blood transfusions

 

Medications:

Does not take any medications on a daily basis

 

Allergies:

1. Shrimp/Shellfish
   1. Anaphylactic reaction
   2. Does not currently have an EpiPen, but notes that she avoids all seafood
2. Peanuts
   1. Urticaria

 

Family History:

• Mother – living, 40 years old – T2DM, diagnosed at age 24; controlled on metformin and insulin
  • Denies any history of HTN, HLD, cancer, heart disease, or any other illnesses
• Father – living – HTN
  • Denies any history of T2DM, HLD, cancer, heart disease, or any other illnesses
• Maternal grandmother – living – T2DM
  • Denies any history of HTN, HLD, cancer, heart disease, or any other illnesses
• Maternal great-grandmother – deceased in 70s – T2DM
  • Denies any history of HTN, HLD, cancer, heart disease, or any other illnesses
• Unable to provide paternal grandparents’ history

 

Social History:

Habits:

OO denies any tobacco, alcohol, and illicit drug use

Travel:

         OO denies any recent travel

Home:

         OO lives at home with her mother, father, and younger brother

Diet:

         OO admits to eating a lot of junk food and carbohydrate-rich foods. She does not eat much protein. She mostly drinks water, but occasionally drinks juice and soda. She enjoys cooking.

Sleep:

         OO typically sleeps for at least 8 hours per night.

School:

OO is going into the 11th grade in the upcoming school year. Her mother reports that she does very well in school and is part of extracurricular activities (dance)

Exercise:

         OO admits to a low activity level. She was more active before the quarantine. She occasionally goes for short walks with her mother in the evenings.

Safety:

OO takes all appropriate safety measures.

Sexual History:

OO denies any sexual activity and history of STIs. Menarche at age 10. Reports that she has a regular 28-day cycle with menstruation that lasts about 5 days.

 

Review of Systems:

General:

 

Denies fever, chills, fatigue, weakness, and loss of appetite.

Skin:

Denies any changes in hair pattern or skin texture or new skin lesions.

Head:

Reports that she hit her head on a chair earlier today when being restrained. Denies headache, confusion, dizziness, loss of consciousness.

Eyes:

Wears corrective lenses. Denies change in vision, eye pain, discharge, crusting, swelling. Reports that her last eye exam was in January 2020.

Ears:

Denies changes in auditory acuity, ear pain, discharge, and foreign body.

Nose:

Denies nasal congestion, rhinorrhea, epistaxis, and foreign body

Mouth/Pharynx:

Denies pain, bleeding gums, sores, sore throat, and change in taste. Reports that she goes to the dentist every year.

Neck:

Denies neck pain and swelling.

Pulmonary:

Denies dyspnea, shortness of breath, cough, and wheezing

Cardiovascular:

Denies chest pain and palpitations.

Gastrointestinal:

See allergies. Denies changes in bowel habits, nausea, vomiting, constipation, diarrhea, abdominal pain, blood in her stool, or any other symptoms.

Genitourinary:

Menarche at age 10. Reports that she has a regular 28-day cycle with menstruation that lasts about 5 days. Denies dysuria, urinary urgency, change in color of urine, blood in urine, abnormal vaginal discharge, menorrhagia, dysmenorrhea, sexual activity, or history of STIs.

Musculoskeletal:

Denies joint pain, swelling, deformity, decreased ROM, or any other abnormalities throughout.

Endocrine:

         See HPI

Neurological:

Denies loss of sensation, paresthesia, or numbness.

Psychiatric:

Denies depression, hopelessness, suicidal ideations, loss of interest in activities, or any family psychiatric history.

 

Physical Exam:

Vital Signs:

Blood Pressure:

                     132/88, right arm, sitting

Heart Rate:

                     88 bpm, regular

Respiration Rate:

                     18 bpm, non-labored

Temperature:

                     98.5 F, oral

O₂ Sat:

                     100%, room air

Height:

                     65 inches

Weight:

                     310 lbs

         BMI:

51.6    

 

General Appearance:

15-year-old female accompanied by mother. Alert and oriented x 3. Well-groomed with good hygiene. Dressed appropriately. In no acute distress.

Skin:

Acanthosis nigricans observed on the lateral and posterior neck. Skin warm and well perfused throughout without any scars or suspicious skin lesions. Good skin turgor. Capillary refill < 2 seconds throughout.

Head:

NC/AT

Eyes:

PERRLA. Cornea clear, conjunctiva pink, and sclera white. EOMI. Visual fields full.

Ears:

Symmetrical without any observed abnormality. No tenderness to palpation of tragus and manipulation of pinna. TMs pearly-gray with cone of light in appropriate position bilaterally.

Mouth/Pharynx:

Mucosa pink and moist. No sores or lesions visualized. Tongue midline. Uvula midline and posterior pharynx rises symmetrically. Pharynx nonedematous without exudates. Good dentition with no obvious caries.

Neck:

Acanthosis nigricans observed on the lateral and posterior neck. No swelling or deformity visualized. Neck supple and nontender to palpation. No masses palpated.  No cervical lymphadenopathy appreciated. FROM without pain.

Chest:

Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation.

Breasts:

Symmetrical bilaterally. No skin or nipple abnormalities. Nontender to palpation without masses or lymphadenopathy. Tanner stage 5 breasts.

Lungs:

 

Clear to auscultation bilaterally with no adventitious lung sounds.

Cardiovascular:

Regular rate and rhythm (RRR); S1 and S2 present without any murmurs, rubs, or gallops.

Abdomen:

Flat protuberant with silvery striae. No observed bulges or pulsations. BS+ in all 4 quadrants. Soft and nontender to palpation throughout. No masses appreciated.

Musculoskeletal:

FROM in upper and lower extremities bilaterally with passive and active motion. No weight bearing limitations or abnormal gait. 5/5 muscle strength in the upper and lower extremities bilaterally. Neurovascular status intact bilaterally

Neurologic:

Alert and oriented x 3. Cooperative and follows commands. Normal speech rate and rhythm

 

Labs:

From PCP on 7/6/2020:

• CBC WNL
• CMP
  • Fasting blood glucose 350 mg/dL
• HgbA1c
  • 8%
• Lipid panel WNL
• Lactate elevated

Finger-stick glucose 7/22/2020 – 274 mg/dL

 

Assessment:

OO is a 15-year-old female with a significant past medical history of Class 3 obesity (BMI 51.6) presents to the clinic with her mother via referral from the Pediatric ED at QHC for evaluation of an elevated HgbA1c level. History, HgbA1c, fasting blood sugar, and random finger-stick glucose are consistent with Type 2 Diabetes Mellitus.

 

Plan:

1. Type 2 Diabetes Mellitus
   1. Metformin 500mg QD at night
      1. Will increase to BID in 3 weeks after assessment for medication tolerance
   2. Glucometer and test strips prescribed
      1. Patient instructed to check blood glucose upon waking, before meals, and 2 hours after largest meal of the day and keep a log to bring to her next visit
      2. Instructed on how to properly check blood sugar
   3. Counselled on nutrition for a diabetic diet
   4. Counselled on diet and exercise
      1. Mother was supportive and wants to help

 

1. 1. Informed that she will have to start insulin therapy if therapy with metformin does not provide desired results
   2. Patient instructed to return to the clinic for a follow-up appointment to assess medication tolerance and review blood sugar results in 3 weeks
      1. Will increase metformin to BID dosing and determine need for insulin
   3. Patient educated on how to properly give insulin to prepare for potential insulin prescription after next visit
   4. Patient and mother reassured and given the opportunity to ask questions; they did not have any at this time but were instructed to contact the clinic with any questions before their next visit.
2. Class 3 obesity
   1. Counselled on diet and exercise

Appointment set up with pediatric nutritionist to help make specific diet plan to manage weight loss