Soap Note

Present Concerns/CC:

“We are here for follow up on labs results after frequent episodes of nose bleeds”

Patient is a 2 years old toddler who lives with both parents and grandmother from his mother side. He attends daycare Monday –Friday from 8-5 and the rest of the time is cared at home by his parents and grandmother. He drinks 8 ounces of whole milk x 3 times daily and eats solid foods. He is described as a good eater, and his diet include rice, beans, meat and yogurt. He does not like vegetables or fruits but parents try to include them. Patient has met all his milestones on time. He knows most colors, speaks 4-5 words sentences and is able to count to 12. Patient is in the process of toilet training and only uses pamper at nighttime. Patient sleeps 8-9 hours at night and 2 hours nap during the day. Patient rides in the back seat of the car. All cabinets are locked at home and house has smoke alarms.

2 y/o male born at 39 weeks gestation via uncomplicated vaginal delivery. Seen in the office accompanied by mother for follow up appointment and labs results. Patient had been seen 1week ago due to complaints of frequent nose bleeds. Last episode 1 weeks ago while in office in the presence of the doctor. Bleeding is usually unilateral but can be present in any nostril. Bleeding is usually of short duration and can be easily controlled with finger pressure. Mother denies bruises, easily bleeding, teeth bleeding or melena. Labs ordered showed an unremarkable complete blood count with only abnormal elevation of PT at 50.

None

Allergies:  NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Immunizations: Up to date

Mother is 28 years old and does not have a past medical history

Father is 36 years old and is healthy. However, he does report similar episodes of nose bleeds since he was a child. He was told it was nose dryness and was never diagnosed with any other disease

Maternal grandmother suffers has GERD.

Maternal grandfather suffers from Hypertension.

Paternal grandmother has Hypertension

Paternal grandfather has hypertension and suffered a TIA 3 years ago but is stable.

History of bleeding disorder of his maternal uncle

Patient lives with both parents and maternal grandmother in a rented house. Both parents are accounting and they are initiated their own office. He goes to daycare since he was 1 year and 6-month-old. Mother reports no guns at home, and they have smoke and CO2 alarms at home. Patient is an only child. He wears helmets for safety when riding bikes. Both parents are highly involved in his care.

Denies weakness, fever, fatigue, night sweats or malaise

Denies abnormal heart beats, murmurs, or chest trauma

Denies rash, hives, urticarial, bruises or lesions

Negative for coughing up blood, respiratory distress or increased respirations

Denies eye redness or discharge

Denies blood in the stool, nausea, vomiting or anorexia

 Denies ear tugging or discharge

Denies cloudy urine or dysuria

Mother reports several episodes of epistaxis.

Negative for nasal congestion, mouth sores or dysphagia

Denies limitation of ROM or joint deformities

Not examined

Denies epilepsy, syncope, hyperactivity or loss of consciousness

Denies anemia, unusual bruising, recent blood transfusions, enlarged lymph nodes, increased thirst. Positive for nose bleeds

Denies sleep problems, anxiety or depression

35 lbs

91.44 cm

Healthy appearing toddler, sitting on his mother’s lap with positive interaction with mother

Normal skin turgor, with warm and intact skin. Capillary refill 2 seconds

Normocepahlic head with even hair distribution. Pupils PERRLA. EOMs intact. Tympanic membranes pink. Patent nasal nares. Septum midline. No obstruction or foreign body observed. Mouth with all teeth and molars without carries. No JVD. Neck supple and with full ROOM.

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Heart rate and sounds with normal findings. No cyanosis, clubbing or edema. S1 and S2 present.

Bilateral lung fields clear. Effortless respirations and chest wall expansion. No wheezing, crackles or Ronchi

Round abdomen without rebound tenderness. BS active x 4.

Not examined

Normal external genitalia. Tenner stage 1

Full head control and normal spine curvature.

Reflexes 2 + throughout. Moro reflex not present. Romberg test negative.

Playful toddler with positive interaction with mother and healthcare provider. No indications of abuse.

CBC: Unremarkable except for PT of 50

1. Von Willebrand Disease (D68.0): This is an inherit condition that produces a deficient clotting protein. Signs and symptoms of the disease include bleeding tendencies such as easy bruising, nosebleeds, heavy menstrual periods in females and other (SMITH, 2017). In this case frequent nose bleeds and the family history suggests this diagnosis.

1. Mild hemophilia A (D68.311): This condition is also characterized by bleeding tendencies and is also an inherited autosomal disease (Karaman et al., 2015).

1. Coagulation defect, unspecified (D68.9): Coagulation defects can be caused by genetics or by conditions such as vitamin K deficiency or liver problems (Karaman et al., 2015). Because this patient exhibits mild symptoms it’s important to include a more general differential diagnosis to determine the cause of the symptoms.

Primary Diagnosis:

. Von Willebrand Disease D68.0

Education

· Educated about diagnosis. This condition affects primarily boys and although sometimes is asymptomatic typical presentation includes bleeding from mucosa and labs showing elevated PT (SMITH, 2017).

· Explain that having this condition predispose the patient to bleeding that can be harder to control. It’s important to wear a medical alert bracelet and inform all healthcare providers of this diagnosis prior to any surgical or dental procedures

· Hematologist must be seen for further testing to determine specific types of the disease and for recommendation of appropriate medical treatment if needed

· When experiencing a nose bleed tilt head slightly forward and provide pressure to the nostril. If bleeding is not controlled seek emergency treatment

· Use helmets and protective equipment to avoid injuries that can produce bleeding.

· Use a soft toothbrush to avoid gum bleedings

References:

Karaman, K., Akbayram, S., Garipardıç, M., & Öner, A. F. (2015). Diagnostic evaluation of our patients with hemophilia A: 17-year experience. Turkish Pediatrics Archive / Turk Pediatri Arsivi, 50(2), 96-101. doi:10.5152/tpa.2015.2516

SMITH, L. J. (2017). Laboratory Diagnosis of von Willebrand Disease. Clinical Laboratory Science, 30(2),