Child Wellness Assessment (Essay Sample)

WELL CHILD ASSESSMENT
Student’s Name
Institutional Affiliation
Course
Date
SUBJECTIVE:
ID: O.K is 4-year-old male patient, DOB 03/1/2017, that came to the clinic accompanied with the mother. Both the child and the mother seem reliable historians.
CC: “I am here for well child checkup”
History of present illness: 4-year-old male is accompanied by his mother for a wellness visit. The mother reports that her 4-year-old son is allergic to peanuts and that the first allergic reaction that occurred when he was 1.5 years old, was taken to the ER because he presented an allergic reaction to wheezing, since then he has always an EpiPen (when the allergy was diagnosed, as verbalized by the mother).
The patient and his mother report the home backup Epi-pen is expired. The mother of the patient reports that he has an allergic reaction like itchy hives all over his body. The patient’s mother denied difficulty breathing or shortness of breath. The patient denies having contact with traumatic injuries or a sick person. Reports good sleeping patterns and nutrition. The mother of the patient denies any previous or current health problems and reports that the patient’s last physical check was in November/2020, with normal examination and lab work findings.
Medications: allergic reaction, vitamins
Medical history: past allergies to peanuts
Surgical history: No past surgeries
Vaccination schedule: Patient’s mother report verbally about the immunization record being current as well as up to date as per age of the patient. Flu shot was the last vaccine administered in October/2020.
Figure 1: Recommended vaccines (Center for Disease Control and Prevention, 2021).


(Center for Disease Control and Prevention, 2021)
Pregnancy, and Birth History: Mother denies use of any illicit drugs, cigarettes, or alcoholic beverages. Reports full term gestation and vaginal delivery of the patient. Patient was breast fed without any difficulty.
Developmental History: Mother reports that the patient achieved all the developmental age-related milestones as appropriated, with no delays.
Feeding History: Patient denies any history of eating/feeding problems and enjoys eating fast foods. Reports he does a good job at avoiding any peanut containing foods.
Family History: The patient is the first child the family. He has a sister who is 2 years old. Mother is healthy and reports the patient’s father being healthy. Mother reports maternal grandmother, maternal grandfather, paternal grandfather and paternal grandmother, all are in healthy status.
Chemicals: mother denies any illicit drugs consumption
Diet: Mother reports the patient consumes fruits, toast/waffle w/ sausage, grilled cheese hotdog or chicken, protein and vegetable. Dessert every other night sprite when out to dinner no juice
Social History: Patient in a Preschool this year. He is independent child. The patient is active and riding bike, playing tennis, and t-ball
Safety: Patient rides bike, plays tennis and t-ball wearing helmet but no pads
Review of systems:
Constitutional: Mother denies loss of appetite, weight loss, chills, fatigue, or fever,
Eyes: Mother denies blurred vision, redness in the eyes, no discharge or itching (last eye check November/2019- normal)
Nose/Mouth/ Ear: mother denies ear concerns
Cardiovascular: mother denies chest pain, heart concerns, no swelling in the legs.
Respiratory: mother denies breathing difficulty or cough
GI: mother denies abnormal bleeding
GU: mother reports no urine concerns
MSK: mother denies ms pain
Integumentary/breast: mother denies rashes
Neuro: mother denies memory loss
Psych: mother denies behavioral change
Endocrine: mother denies urine concerns
Hematologic/lymphatic: Mother denies bruising
Allergy: mother reports allergy to peanuts but denies seasonal allergies
OBJECTIVE:
Vital signs: P: 88 BP: 90/58, RR: 22 T: 98.4 Pain: 0/10
Height: 40 inches Weight: 40 Lbs. BMI: Normal weight
Growth chart: 75 percentiles of BMI for ages, boys, Birth to 5 years-old (World Health organization, 2006)


Figure 2: Growth chart: 75 percentiles of BMI for ages, boys, Birth to 5 years-old (World Health organization, 2006)
Physical exam:
General survey: Patient appears active, alert, and comfortable with eye contact with the mother
Head: symmetric, no bumps noted. Normal hair distribution
Eyes: No exophthalmos present. The eyes are symmetrical. Pupils are consensual and directly react to light directly. Visual acuity with help of corrective glasses at 20/20 vision
Ears: No redness, no drainage or tenderness noted. Eardrums intact, no retraction
Nose: bilateral nostrils, no swelling or drainage noted
Throat/mouth: Gums are moist and pink in color, no swelling or drainages noted.
Neck: Trachea is midline, no palpated lymph nodes, no enlarged thyroid gland noted
Respiratory: No wheezing, or accessory muscles used
Cardiovascular: Rhythm and rate noted regular, no additional heart sounds noted.
Abdomen: Relax and soft, no pulsations or tender noted. No enlarged organs noted.
GU: No tenderness on palpation, bladder not distended
MKS: ROM intact, normal gait. No pain noted. Palpable popliteal, dorsalis pedis, and femoral pulses.
Skin: No rashes or scars noted. Nails capillary refill less than 2 seconds. Good skin turgor and elasticity
Face: No rashes or scars, no discoloration noted
Upper/Lower Extremities: No discoloration, lesion or rashes noted
Neuro: Oriented and alert. No unilateral weakness. No pathologic reflexes noted.
ASSESSMENT:
Health maintenance, well child visit as recommended per guidelines (Riley et al., 2019).
Patient should follow the check visit as by the direction of the doctor/nurse
Allergies, related to peanut allergy (Loh & Tang, 2018).
Allergies prevalence high among the children
Symptoms: difficulty breathing, wheezing, indigestion, vomiting, diarrhea, stomach cramps
Introduce foot containing peanuts like cereals, candy, baked foods to prevent peanut allergies
Review of immunization’s schedule, as recommended per CDC guidelines (Center for Disease Control and Prevention, 2021)
Patient should observe the immunization schedule for children between 4-6 years
Patient should be administered 4 categories of vaccines for immunization: DTaP, IPV, MMR, and Varicella
Varicella vaccine- to protect against chickenpox, a health condition characterized by fever, headache, tiredness, rashes
DTaP vaccine-to protect against diphtheria, symptomized by sore throat, weakness, mild fever
IPV vaccine-to protect against polio, characterized by fever, headache, nausea,
MMR vaccine- to protects against mumps, health condition characterized by fever, muscle pain, tiredness, headache
In this patient, I will also consider the following Risk Assessments:
Risk for accidents: Related to the adolescent’s unsafe behavior
Patient not using helmet while playing
Patient not using knee straps while playing (Locke et al., 2019).
Risk for unhealthy diet: Related to children eating unhealthy foods
Patient should avoid fast foods and sugar foots like sprite
PLAN:
Treatment
Renew Epi pen prescription. Sent electronically to pharmacy-EpiPen Jr. An Injection of 0.15 mg/0.3 mL, single-use IM or SubQ injection as needed for allergic reaction (intramuscularly into fatty part of the body like the thigh’s anterolateral aspect, necessarily through clothing) (Voelker, 2018).
Referrals
Referral to a dietician for implementation of an adequate meal plan, acco