HPI: M.M. is a 5 y.o. F who present to HU clinic with her mother for nightmares. She was recently evaluated at the clinic 1 month ago for her 5-year-old well child checkup.

HPI: M.M. is a 5 y.o. F who present to HU clinic with her mother for nightmares. She was recently evaluated at the clinic 1 month ago for her 5-year-old well child checkup. Developmental, behavior showed no concerns at that visit. Mother reports nightmares started 3 months ago but now they are occurring more frequently at least twice per week. Mother reports M.M. going to bed around 9PM and normally by 11PM she is up screaming, confused and clammy. Mother and father are unable to get her to calm down during these episodes. M.M. will eventually calm down and fall back asleep. She usually wakes up at 6:30 AM to start to get ready for school. Mother denies any recent changes in her home life, she did start kindergarten and also a soccer league (practice twice a week for an hour with 30-minute games on the weekend). M.M. reports not remembering these episodes. She reports still enjoying school and has made a new friend name “Jaden.” They are in class together and on the same soccer team.

 

PMH: Born at 39 weeks’ gestation via cesarean section for being in a breech position. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant was breastfed. Allergies: No known drug allergies

 

Medications: Disney Princess Gummy Vitamin

 

Social History: The child lives with her mother and father who have been married for 2 years. Both parents work full-time. She started public school two months ago which is full day kindergarten. Father vapes in the home. Both parents report social drinkers on the weekend, “couple of beers with dinner.”

 

There are no firearms in the house.

 

Family History: Mother and father deny any significant medical history.

 

Health Maintenance/Promotion: Immunizations are up to date including this season’s flu vaccine.

 

Review of Systems

 

General: Denies any concerns, unexplained fevers, or growth and developmental concerns.

 

Skin: Denies any rash, lesions, or concerns with eczema.

 

Head: Denies headache, trauma or falls.

 

ENT: Denies any concerns with ears, nose, or throat.

 

Neck: Denies pain with ROM neck. Denies masses or lumps.

 

CV: Denies any chest pain, cyanosis, heart racing or sweating.

 

Lungs: Denies any cough, congestion, wheezing, or difficulty breathing.

 

GI: Denies food intolerances. Denies weight loss, nausea, vomiting, constipation or diarrhea.

 

GU: Negative for burning or blood in urine. Musculoskeletal: Denies pain, trauma, numbness.

 

Neurological: denies changes in senses. Psych: Denies difficulty concentrating, tearful episodes, anxiety

 

or seclusion. Endocrine: Denies increase thirst or urination. Hematologic: Denies bruising or bleeding.

 

Objective

 

VS: Temperature: 99.2 F, 99/59, HR: 89, RR: 22, 100% on RA, Ht: 55 in (93.52%), Wt.: 97 lbs. (98.3%),

 

BMI: 22.54 (97%).

 

General: Well developed, well-nourished and hydrated, no apparent distress. Appropriate dressed.

 

Skin: No evidence of rash or lesions.

 

Head: Normocephalic.

 

Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red

 

reflex present bilaterally.

 

ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes.

 

Hearing is grossly normal. Dental caries B, C, M, L. Mild erythema and swelling gingivae. Oropharynx:

 

normal mucosa, palate, and posterior pharynx.

 

Neck: Supple and no lymphadenopathy.

 

CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No

 

murmurs. Femoral pulse 2+ bilaterally.

 

Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on

 

auscultation without rales, rhonchi, or wheezes.

 

Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed.

 

MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.