Neida CaroboonetranscriptionAdvanced ReportNeurology TE ^N4
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Valencia College *
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1611C
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Medicine
Date
Dec 6, 2023
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Uploaded by BrigadierFang12455
Neida Caro-Boone
Neurology TE #4 Neurology SOAP Note: Autism
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN (SOAP)
Patient Name:
Carmen Jean Lopes
PCP:
Dr. Sandra Peebles, MD
Patient ID:
LOP165
DOB:
06/01/----
Age:
7
Sex:
F
Date of Visit:
08/05/--
Problem #1:
Rectal Warts.
SUBJECTIVE:
Patient is here for consent forms to be filled out and to discuss
some other issues; but Mom and Dad’s primary concern is that when
washing her in the last few weeks, they have noticed some skin tag like
lesions near the rectum and want them checked. She has not scratched or
irritated them. No previous history. Mom and Dad both do report they get
warts on their hands from time to time and do not wear gloves when they
wash Carmen Jean.
OBJECTIVE:
The patient is in her usual semi agitated mode. She is calmer
with her father. She certainly interacts well with both parents. Skin is warm
and dry to touch. Respiration is full and adequate. No vitals were done. Skin:
Rectal area, no redness or edema but there are definitely 5 or 6 or even 8
wart like lesions in various sizes surrounding the anus. They do have cream
on them, so it is a little hard to give it a description. Dr. Peebles examined as
well and verified.
ASSESSMENT:
Warts, most likely viral in nature.
PLAN:
I had a lengthy discussion with mom and dad regarding etiology,
caring for them, hygiene issues, etc. We will try Aldara as directed. Dr.
Peebles suggested a RPR when she has some upcoming blood work, and we
will get that done. There is no concern in Dr. Peebles or my opinion that
anyone could get near her in a sexual way, as she would kick and fight and
scream. Her parent’s actually initiated that comment. Recheck pending
progress, and they will call in a few weeks to tell me how things are going.
Problem #1:
Autism and Seizure Disorder
.
SUBJECTIVE:
Carmen Jean continues to live with a supportive staff. I believe
she is at home at this point. I did not clarify that, but that is the sense I get in
the way care taking was described. Mom and Dad are very
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN (SOAP)
Patient Name: Carmen Jean Lopes
Patient ID: LOP165
Date of Visit: 08/05/--
Page 2
involved in her health care, physical, and daily care. She is learning to
respond “yes” and “no” on an I touch phone. They just bought an iPad to try
to help with that communication. A big concern on both parent’s part is that
the neurologist is thinking of stopping the Dilantin and switching to a
different seizure medicine, as there has been some concern that Carmen
Jean is having some breakthrough minor seizures when she is tired and
agitated. No one is 100% sure that is what is going on. Mom is very hesitant
to change the medication, but there is a plan in process if they do switch; the
decision has not been made yet.
OBJECTIVE:
Carmen Jean is as Carmen Jean always is.
ASSESSMENT:
1.
Severe Autistic Disorder.
2. History of significant seizure disorder.
PLAN:
Consulted with parents for 25 minutes today, discussing all of the
above issues. They need to do what is best for them, best for Carmen Jean,
and at the advice of someone they trust. They are working with a neurologist
whom they trust and will recheck PRN.
________________________
Greg Farrow, FNP
GF:ncb
D:08/05/----
T:08/05/----
C:Dr. Sandra Peebles, MD, Internal Medicine
Dr. Wanda P. Dale, MD,
Neurology
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