CHOOSE ONE THE FOLLOWING TOPICS AND SUBMIT A SOAP NOTE. USE YOUR TEXTBOOK AND A CLINICAL GUIDELINE TO SUPPORT YOUR COMMENTS
Atrial Septal Defect
Attention Deficit/Hyperactivity Disorder
Autism Spectrum Disorder
Chicken Pox
Cerebral Palsy
Cor Pulmonale
Croup
Cryptorchidism
Down Syndrome
Hand-Foot-and-Mouth Disease
Kawasaki disease
Reye Syndrome
SOAP NOTE RUBRIC:
CHIEF COMPLAINT
PAST MEDICAL HX
HPI
ROS
PE
PRIMARY DIAGNOSIS
AT LEAST THREE DIFFERENTIAL DIAGNOSIS
PLAN OF CARE
Autism Spectrum Disorder
CHIEF COMPLAINT: The patient is a 4-year-old male who was brought in by his parents for a routine check-up. They have concerns about his behavior and social interactions.
PAST MEDICAL HISTORY: The patient has no significant past medical history.
HPI: The parents report that the patient has been exhibiting repetitive behaviors such as rocking back and forth and flapping his hands. He has difficulty communicating and making eye contact with others. The parents have noticed that the patient prefers to play alone and has difficulty interacting with other children. They also report that the patient has a history of delayed milestones such as delayed speech.
ROS: The patient has no history of fever, chills, or night sweats. There are no respiratory or gastrointestinal symptoms. The patient has no history of seizures or any other neurological symptoms.
PE: The patient’s vital signs are within normal limits. On physical examination, the patient appears to have difficulty making eye contact and has a flat affect. The patient exhibits repetitive behaviors such as hand flapping and rocking. There are no significant findings on neurological examination.
PRIMARY DIAGNOSIS: Autism Spectrum Disorder
AT LEAST THREE DIFFERENTIAL DIAGNOSIS:
- Attention Deficit/Hyperactivity Disorder
- Intellectual Disability
- Social Communication Disorder
PLAN OF CARE: The patient will be referred to a developmental pediatrician for further evaluation and management of Autism Spectrum Disorder. The patient will also be referred to a speech therapist for further assessment of his speech delay. The parents will be counseled on behavioral interventions that can be implemented at home. Follow-up appointments will be scheduled to monitor the patient’s progress and adjust the management plan as needed.