Case Study

Directions:
1. Please read the soap note below. This is a patient who presents to your office. Then formulate a minimum of 3 differential diagnoses for the presenting problem and thoroughly explain your rationale for each diagnosis. You must use evidenced-based literature (references) to support each of your chosen diagnoses.
2. After deciding on your final diagnosis, explain why you chose this diagnosis over the others.
3. Then you will formulate a comprehensive thorough assessment and plan based on your final diagnosis given clinical history and physical exam.
4. For this case study you must address the plan for all other established health problems/ incidental findings, emerging diagnoses in your plan.
5. Don’t Forget: Your plan should include: evaluations, screenings, diagnostic studies you want to complete/order today? Also note any teaching or anticipatory guidance based on knowledge deficit you’ve identified. Any referrals? Remember every step of plan needs a reference.
6. Please include a thorough follow up plan at the end of the soap note.
Subjective
Jackson Price is a 3 year old male who presents today with both mom and dad for visit.
CC: “We are here with Jackson today we have some concerns.”
History of Present Illness:
Mom states “I’ve noticed Jackson has some odd behaviors that concern me”. She reports that Jackson goes to daycare 5 days per week, and the teacher at daycare expressed concern about Jackson’s behavior. Both mom and teacher have noticed he does not respond to his name, avoids eye contact, repeats words and phrases over and over, doesn’t use pretend play, often demonstrates lack of fear, gets upset easily, and is frustrated by small changes in his daily routine. Mom reports he does not play well with other children.
Of note, Jackson has not seen a healthcare provider since he was 11 months old. He is not up to date on vaccinations. Mom reports he has not seen a provider because “he has not been sick and has not needed a visit”. He is not potty trained—mom reports she has tried for several months without success. With regards to nutrition, mom reports Jackson has a very limited diet. She tries to provide Jackson with a balanced diet, but he is a picky eater and does not like food of certain colors and textures—especially fruits/vegetables. She states she tries to make up for his limited diet with a daily multivitamin and “lots of fruit juice” (about 4-5 cups per day).

Past Medical History:
Born at 39 weeks and 2 day, 6lb 5oz, 18 inches (no NICU stays, no hospitalizations since)
Eczema, Neonatal jaundice (since resolved)
Past Surgical History:
Cleft lip repair at 5 months old, circumcised
Family History:
Both mom and dad were adopted- No known Family Medical History
Mom: 43 y/o, GERD
Dad: 47 y/o, Healthy
Medications:
Children Tylenol PRN
Children Motrin PRN
OTC Medications:
Multivitamin gummy
Herbal and Supplements:
None
Allergies:
NKDA, food and environmental allergies
Social:
Lives in house with mom/dad in single family home built in 1950s—both parents work 9-5 in office setting. No siblings. No secondhand smoke exposure. Uses car seat. Mostly sleeps with mom and dad—sleeps through the night typically 8-10 hours. Their residence contains no pets
Health Maintenance:
Childhood vaccines were completed until 6 month old. Passed hearing screen at birth. No annual flu shot. Last dental visit 1.5 years ago.
Review of Systems:
General: Denies any recent weight change or change in appetite/diet, no fever, no change activity level
Skin: Reports multiple areas of dry skin that is intensely pruritic (antecubital fossa, wrists, and neck); denies bruising, open wounds/lesions
HEENT: Denies any headaches, visual changes, ear pain, or dysphagia. No photophobia, runny nose, ear pain, +reports patient is averse to loud noises
Neck: Denies any neck stiffness
Cardiovascular: Denies shortness of breath, sweating, color changes with eating, chest pain, palpitations, fainting, or dizziness with activity
Lungs: Denies any shortness of breath, no cough
GI: Denies dysphagia, nausea, vomiting, abdominal pain, diarrhea, or hematochezia
Musculoskeletal: No weakness, contractures, or clubbing
Psychiatric: As documented in HPI—also reports some separation anxiety, rarely laughs or smiles
Communication: uses about 40 words; mostly points to objects. Per mom, he is unable to follow 2-step instructions. She reports excessive crying, and he is often hard to console
Motor activity: Has difficulty with stacking blocks; Mom reports he cannot draw circles. Able to feed self although cannot use fork

Objective:
Vital signs: 90/60 mmHg, RR 18, 90 bpm, 99% o2 saturation, 98.6 F, BMI 14.6 (5th percentile for weight; 50th percentile for height)
Physical Exam
General: Pt is sitting up, preoccupied with toy. Appears comfortable
Head: normocephalic, nicely healed cleft lip scar
Eyes: pupils equal, round, reactive to light, conjunctiva clear and conjugate gaze
Ears: Difficult to assess as patient is uncooperative; TMs and canal grossly without erythema, edema, or drainage
Nose: clear, no discharge
Oral: OP patent without erythema or edema; about 20 teeth present–+obvious dental caries in several teeth. No loose teeth, gingival or facial swelling
Neck: supple and no lymphadenopathy
Lungs: clear to auscultation bilaterally
Heart: regular rate and rhythm, no murmur. Peripheral pulses palpable and symmetric
Abdomen: normal bowel sounds, soft, non-distended, no hepatosplenomegaly or masses
Neuro:
Pupils PERRLA, EOMs intact, no obvious nystagmus, visual acuity NT
Mental status/Affect: Withdrawn, +stranger anxiety, intermittently crying
Able to state first name
Behavior/Speech: Follows one step commands only, easily distracted
Answers most questions yes/no—does put 2-3 words together to form phrases; phonation clear
Motor: Normal tone; Moves all extremities independently; gait steady
Fine motor coordination: Able to pick up small item with one hand, Jumps with two feet, Only able to make block tower up to 3 block tower without falling; Can copy straight line, cannot copy/draw circle; Has difficulty balancing on one foot
Motor: Normal tone; Moves all extremities independently; gait steady
Reflexes: NT—does not tolerate exam
Musculoskeletal: back straight, no evidence of scoliosis, no defects, full passive ROM in all extremities +prominent spine, +prominent ribs bilaterally
Genitalia: Normal male, Tanner stage, I , +wearing diaper
Rectal: anus normal to inspection
Skin: warm, no ecchymosis, +dry, erythematous scaly plaques on antecubital fossa bilaterally

Differential Diagnosis
1. Autism Spectrum Disorder (Explain why you chose this diagnosis)
2. Lead Toxicity (Lead Poisoning) (Explain why you chose this diagnosis)
3. Attention Deficit Hyperactivity Disorder (Explain why you chose this diagnosis)
4.
(Thoroughly explain your rationale for each diagnosis. You must use evidenced-based literature (references) to support each of your chosen diagnoses)

Working Diagnosis
Autism Spectrum Disorder (Explain why you chose this diagnosis over the others. Then you will formulate a comprehensive plan based on this diagnosis)
(After deciding on your final diagnosis, explain why you chose this diagnosis over the others).

Assessment

Plan
(For this case study you must address the plan for all other established health problems/ incidental findings, emerging diagnoses in your plan.
Don’t Forget: Your plan should include: evaluations, screenings, diagnostic studies you want to complete/order today? Also note any teaching or anticipatory guidance based on knowledge deficit you’ve identified. Any referrals? Remember every step of plan needs a reference.)

Follow-up
(Please include a thorough follow up plan at the end of the soap note.)