Reference no: EM133657622

Read the case study and decide what is pertinent. Then place the components in the correct subjective and objective sections of the SOAP note form attached below.
Find areas that you desire more data (questions that you would ask if you were interviewing/assessing this patient). You will write in red on your SOAP note those further inquiries. Minimum of 8 additional data points (2 in history, 2 in HPI, 2 in ROS, 2 in exam) that you will insightfully add to the data provided.
Continue on to the assessment and plan of your SOAP form where you will give differential diagnoses, supply pertinent positives and negatives, pick your two medical diagnoses, and finish out the health profile.
Complete the plan, rationale, and pathophysiology sections (these will be only on your medical diagnoses that you have determined, not on all differential diagnoses.)
The last item will be to complete the case study follow-up questions at the end of this prompt. You will place these at the end of your SOAP document.

Micah Jones is a nine-month-old African-American female who comes to your outreach clinic for an initial evaluation. She is accompanied by her mother, who speaks Arabic and English. The mother is concerned that Micah is not developing like other children her age. The family immigrated from Sudan one year ago and now lives in low-income student housing because the father is in graduate school. This is their first child. The maternal grandparents are also temporarily living in the household to help out with Micah.

 

Your review of Micah's birth history reveals the following information. Micah was born 11 weeks early and weighed only 2.5 pounds. According to the mother, the doctors were surprised to see what a strong and active girl she was. However, when Micah was just a few days old, she stopped breathing and was put on a ventilator. After 24 hours, she was able to breathe on her own. According to the mother, the doctors ran a lot of tests to find out what had happened, but they couldn't find anything wrong. The remainder of Micah's time in the hospital was uneventful, and she went home after two months.

The mother responds she had limited access to prenatal care. She denies use of alcohol cigarettes or drugs. The pregnancy was uneventful, with the exception of premature labor and rupture of membranes. Micah spent two months in the NICU. Since discharge Micah has not had any hospitalizations, surgeries, or injuries. Micah is frequently congested and easily becomes ill with respiratory infections. The family history of diseases is unremarkable.

The infant is not currently taking any medications. She is behind on her immunizations because Micah has yet to receive her six-month series. She previously received immunizations at a local health department but medical care has been sporadic because of the family moving shortly after Micah came home from the NICU. The family has limited resources and has been unable to locate a primary care physician. Interim care has been obtained at multiple urgent care clinics.

The mother gives Micah baby formula and offers baby food to three times per day. She believes Micah doesn't like the baby food because she frequently pushes it out with her tongue. Micah is difficult to feed because she frequently coughs while eating or drinking and she drools a lot. As for elimination, the mother reports 5 wet diapers per day with a bowel movement consisting of balls of stool every other day. Micah's sleep has improved, although she continues to wake up during the night, crying and arching her back. The mother notes that her legs become stiff.

Developmentally, Micah has a social smile, makes few vocalizations, and enjoys being held. She is able to pick up small objects with her hands but does not transfer them. The mother feels she makes good eye contact and tracks objects.

Micah is cared for by her grandmother and mother during the day.

Upon physical examination, you find a thin normocephalic female infant in no acute distress. Corrected gestational age is noted to be six months and one week old. Length is between the third and fifth percentile with weight below the third percentile. Ophthalmoscopic examination revealed strabismus. Examination of the oropharynx reveals an intact pallet with a positive gag reflex. Drooling is evident. The abdomen is rounded and palpation reveals stool. You focus special attention on the neurological examination. Muscle tone is greater in the lower extremities and the upper extremities, with clonus at the ankles. At times she exhibits hyperextension and adduction (scissoring) of the lower extremities. Deep tendon reflexes are brisk. She exhibits head lag when pulled into a sitting position and has poor trunk control. Primitive reflexes (asymmetric tonic neck reflex and moro reflex) are present. The remainder of the physical examination is within normal limits.

Case study follow-up questions (place these at the end of your SOAP note.)

What parts of the physical examination will be particularly important for this child?
Does Micah have developmental delays for a six-month-old corrected age infant? If so, in what areas?
How would you treat her constipation?
What is your plan and interventions for her feeding status? (if not addressed in SOAP plan)
What would you educate the family about considering gross motor delays and suspected cerebral palsy?
Is cerebral palsy preventable?