NRNP 6541 iHuman Case Week #7 Pediatric Primary Care Clinical Case Analysis ,a 22 months old female girl is having Difficulty in making friends:full case with soapnote
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Course: NNRP 6541 Case Week: #7 Patient: Pediatric Female Age: 22 months Weight: 12.7 kg (28 lb) Height: 84 cm (33 in) Setting: Outpatient Pediatric Clinic Chief Concern: Difficulty making friends
CHIEF COMPLAINT (CC)
“My daughter doesn’t interact with other children and prefers to play alone.”
HPI (History of Present Illness)
Questions & Parent Answers
1. When did you first notice a problem?
About 6 months ago.
2. What concerns you the most today?
She doesn’t interact with other children.
3. Has this behavior gotten better, worse, or stayed the same?
It has stayed the same.
4. Does she make eye contact with you?
Sometimes, but not consistently.
5. Does she respond when her name is called?
Not always.
6. How does she behave around other children?
She prefers to play alone.
7. Does she imitate actions or sounds?
Very rarely.
8. Has she lost any skills she previously had?
No.
9. Does she use words to communicate?
She uses a few single words.
10. Does she show interest in playing with others?
No, she usually ignores them.
ROS (Review of Systems)
Questions & Answers
General
1. Any fever or weight loss?
No.
2. Any fatigue or changes in activity?
No.
HEENT
3. Any hearing concerns?
Not that I’ve noticed.
4. Does she respond to loud noises?
Yes.
5. Any vision problems?
No.
Respiratory
6. Any coughing or breathing problems?
No.
Cardiovascular
7. Any bluish lips or fainting episodes?
No.
Gastrointestinal
8. Any vomiting, diarrhea, or constipation?
No.
Genitourinary
9. Normal urination and wet diapers?
Yes.
Neurologic
10. Any seizures or abnormal movements?
No.
Psychiatric / Behavioral
11. Does she have frequent tantrums?
Sometimes with changes in routine.
12. Does she engage in repetitive behaviors?
Yes, she lines up toys.
PMH (Past Medical History)
Questions & Answers
1. Was she born full term?
Yes.
2. Any pregnancy or birth complications?
No.
3. NICU stay?
No.
4. Any hospitalizations?
No.
5. Any surgeries?
No.
6. Any chronic illnesses?
No.
7. Is she up to date on immunizations?
Yes.
8. Any prior developmental concerns?
No.
PE (Physical Exam)
Examiner Observations & Findings
1. General appearance?
Alert toddler, limited engagement.
2. Eye contact with examiner?
Minimal.
3. Response to name?
Inconsistent.
4. Head and facial features normal?
Yes.
5. Tympanic membranes intact?
Yes.
6. Heart sounds normal?
Yes, no murmurs.
7. Lung sounds clear?
Yes.
8. Abdomen soft and non-tender?
Yes.
9. Muscle tone normal?
Yes.
10. Neurologic reflexes appropriate?
Yes.
PA (Physical / Developmental Assessment)
Questions & Answers
1. Can she walk independently?
Yes.
2. Does she run or climb?
Yes.
3. Can she stack blocks?
Yes.
4. How many words does she say?
About 10–15 words.
5. Does she combine words?
No.
6. Does she follow simple commands?
Sometimes.
7. Does she point to objects she wants?
Rarely.
8. Does she wave goodbye?
No.
9. Does she engage in pretend play?
No.
10. Does she play alongside other children?
No.
HIGH-YIELD EXAM NOTE
These Q&A pairs directly trigger points for:
• Developmental delay
• Autism screening (M-CHAT-R/F)
• Early intervention referral
HISTORY OF PRESENT ILLNESS (HP