Ms. Jones has brought her 15 month-old Lucy to clinic today…
Ms. Jones has brought her 15 month-old Lucy to clinic today for a well child exam and there are no stated concerns at first asking. She was a no-show for the 12 month WCC. History reveals that Lucy’s parents both work full time and Lucy attends full time in-home daycare. Additional information indicates that Lucy is a ‘light eater’ and prefers beverages (mostly milk and water). Mom thinks she drinks 6 or 7 glasses per day… more than 34 ounces per day. Past medical history and family medical history are noncontributory. Review of systems and physical exam suggest no medical concerns. Developmental screening is within normal limits using the Ages & Stages Questionnaire. Immunizations not current due to missed 12 month appointment. Hgb was drawn before you saw patient with result of 9.0. Obviously, there is much additional information that would be helpful, but write an assessment that reflects your basic thoughts identifying all issues that ideally need to be addressed. Include routine health supervision as well as any additional issues you wish to address. Then, create a succinct, but detailed, plan to accompany your assessment, be sure to include rationale. Assessment: 1. 2. 3. Plan: Rationale: Considering all you’ve learned about well childcare and psychosocial issues, prepare a rationale so that you reflect knowledge of why you have decided on your plan of action. Number your rationale to correspond to your plan.
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