DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Sickle cell beta plus thalassemia.
INTERVAL HISTORY: The patient returns to the pediatric hematology/oncology clinic for followup. Since the last clinic visit, the family has moved. The patient comes accompanied by his foster mother and foster father. The patient is now a (XX)-month-old boy with diagnosis of sickle cell beta plus thalassemia. His hemoglobin electrophoresis six months ago showed a hemoglobin S of 47%, hemoglobin F of 32%, hemoglobin A of 17%.
The patient has been asymptomatic since his last clinic visit six months ago. However, foster mother says that at times he complains of lower extremity pain, which apparently improves with just massage. He has not been hospitalized for vaso-occlusive pain crisis or any other sickle cell disease related complications. The patient is an oral breather. He snores at night and has frequent congestion despite his Claritin.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, weight loss or other constitutional symptoms.
SKIN: No rashes, petechiae, bruising or eczema.
HEENT: No vision or hearing problems. No nasal congestion or epistaxis. No mouth pain or difficulty swallowing.
RESPIRATORY: No cough, congestion or difficulty breathing.
CARDIOVASCULAR: No history of heart disease.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, melena or hematochezia.
GENITOURINARY: No hematuria or dysuria.
MUSCULOSKELETAL: No joint pain or dactylitis.
NEUROLOGIC: Normal developmental milestones.
HEMATOLOGIC: History of sickle cell beta plus thalassemia.
MEDICATIONS:
1. Claritin 5 mg p.o. once a day.
2. Albuterol sulfate HFA 90 mcg inhaler 1-2 inhalations every 4-6 hours as needed for wheezing.
3. Nasonex 50 mcg spray 2 sprays intranasally every day.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert, happy, in no distress. He is cooperative during the examination.
VITAL SIGNS: Temperature 97.8, pulse 142, respirations 26, blood pressure 110/70, weight 13.2 kg (25th percentile), height 89.6 cm (25th percentile), and oxygen saturation 100% on room air.
SKIN: No paleness, rashes, petechiae or bruising.
HEENT: Normocephalic. Pupils are equally round and reactive. Extraocular muscles are intact. Conjunctivae are clear. Tympanic membranes are pearly gray. Oropharynx is pink and moist. Tonsils are generous for his age, but there is no exudate. His nares seemed congested. There is oral breathing.
LYMPHATICS: No palpably enlarged nodes in the neck, axillae or groin.
CHEST: Clear to auscultation throughout.
HEART: Regular rate and rhythm without murmurs.
ABDOMEN: Soft and benign without organomegaly or masses.
EXTREMITIES: Warm and well perfused without cyanosis or edema.
NEUROLOGIC: Nonfocal.
IMPRESSION:
1. The patient is a (XX)-month-old boy with sickle cell beta plus thalassemia.
2. Hereditary persistence of hemoglobin F.
3. Seasonal allergies with what appears to be chronic rhinitis and probably inflammation of tonsils and adenoids with obstructed nasal breathing.
PLAN:
1. Today, we recommended to the family to schedule an appointment with Dr. Jane Doe to discuss the fact that he probably has congested upper airways. He may need further treatment with Flonase and referral to ENT for further evaluation. Dr. Jane Doe may need to consider the possibility of referring him for a sleep study after evaluation from ENT to determine whether he has impaired sleep secondary to nasal obstruction.
2. Regarding his blood work, at the family’s request, we decided not to proceed with further testing. His H&H recently was 11.9. His hemoglobin was 11.9 a couple of weeks ago.
3. The family has recently moved. We would like to refer him back for ongoing care.
4. At this point, we think it will be reasonable to continue to monitor his reactive airway disease, but we would recommend referral to pediatric pulmonology if his condition does not improve.
5. The family knows to call or return if his condition worsens in any way.
6. For his lower extremity pain that appears only intermittently, we have suggested the family to give ibuprofen 100 mg/5 mL, 7.5 mL every 8 hours as needed for pain. If that does not improve and he continues to experience pain, he may benefit from treatment with hydrocodone.
7. The family knows to call or return if his condition worsens in any way.
