General Paeds Consult Medical Report

Re: Alice Smith, 7 years old (DOB: 12/03/2017) Address: 123 Oak Street, Anytown, AB1 2CD Hospital Number: H-78901 Seen on: 1 November 2024 With: Mother Clinician: Dr. Eleanor Vance Dr. Thomas Kelly kelly.gp@example.com 456 Pine Avenue, Anytown, AB1 2DE Problem List: 1. Persistent nocturnal enuresis 2. Mild anxiety related to school performance 3. Frequent upper respiratory infections Medications: 1. Desmopressin 0.2mg orally at night (as needed for enuresis) 2. Multivitamin once daily Discontinued Medications: 1. Amoxicillin (stopped 2 weeks ago, completed course for ear infection) Presenting Complaint: Alice's mother reports persistent bedwetting, occurring almost nightly, despite various interventions. History of Presenting Complaint: I had the pleasure of reviewing Alice Smith who is now 7 years old. Alice attended with her mother. Alice's mother states that Alice has been experiencing nocturnal enuresis since toilet training completion, with a recent increase in frequency over the last six months, now occurring almost nightly. She reports that Alice often sleeps very deeply and is difficult to wake. They have tried restricting fluids before bed, using an alarm, and sticker charts, all with limited success. Alice occasionally wets the bed during naps as well. Alice's mother expresses concern about the impact on Alice's self-esteem and social activities, as she is hesitant to have sleepovers. Alice has also expressed some embarrassment about the issue. Her mother notes that Alice's school performance has been generally good, but she has recently shown some signs of anxiety, particularly around tests. She becomes withdrawn and sometimes cries before school on test days. No reported suspensions or aggression at school, but Alice has mentioned feeling worried about not doing well enough. They are currently receiving support from the school counsellor for the anxiety. At home, Alice is generally a happy child but can become frustrated easily when she struggles with homework, sometimes leading to tears. Her mother reports some parental stress due to the persistent bedwetting and the impact it has on family routines and laundry. Alice enjoys playing with her younger brother and participates in a weekly swimming club. Alice sees a school counsellor once a fortnight for her anxiety, with goals focused on coping mechanisms and self-regulation. The therapist's name is Ms. Sarah Jenkins, located at Anytown Primary School. ROS: Negative for recent fevers, chills, unexplained weight loss, or changes in appetite. No dysuria or increased daytime urinary frequency reported. No abdominal pain, constipation, or diarrhoea. Respiratory system is clear, occasional cough during URIs. Cardiovascular and neurological systems appear normal. Alice's mother reports Alice occasionally complains of restless legs at night. Birth History: Born full-term at 39 weeks via spontaneous vaginal delivery with no complications. Birth weight 3.2 kg. No neonatal complications. Past Medical History: Occasional upper respiratory infections, ear infections (last one 2 months ago). No chronic medical conditions. No significant accidents or injuries. Past Surgical History: None. Immunisations: Up to date as per UK national schedule. Allergies: No known drug or food allergies. Family History: Father has a history of nocturnal enuresis until age 9. Maternal grandmother has anxiety. No family history of significant genetic disorders. Social History: Alice lives at home with both parents and a 4-year-old brother. Parents are supportive and engaged. Father works full-time, mother works part-time. Stable home environment. Diet: Alice eats a varied diet with a good intake of fruits and vegetables. She avoids sugary drinks, especially before bedtime. Her mother ensures she drinks plenty of water throughout the day. Development: Met all developmental milestones appropriately. Good social interaction and bonding with family. Physical Exam Vitals: Temp: 36.8°C, Pulse: 85 bpm, RR: 18 breaths/min, BP: 95/60 mmHg, O2 Sat: 99% on room air. Growth Parameters: Weight: 25 kg (50th percentile), Height: 125 cm (75th percentile), Head Circumference: 52 cm (50th percentile). General: Alert, cooperative, well-appearing child. No acute distress. HEENT: Normocephalic, atraumatic. Conjunctivae pink, sclerae anicteric. TMs clear bilaterally. Nares patent. Oropharynx clear, no erythema or exudates. No cervical lymphadenopathy. Cardiovascular: S1S2 regular rate and rhythm, no murmurs, rubs, or gallops. Capillary refill <2 seconds. Respiratory: Lungs clear to auscultation bilaterally, no wheezes, crackles, or rhonchi. No respiratory distress. Abdomen: Soft, non-tender, non-distended. Bowel sounds present. No organomegaly. Genitourinary: Normal external female genitalia, no signs of irritation or infection. Musculoskeletal: Full range of motion in all extremities. No joint swelling or tenderness. Normal gait. Neurological: Cranial nerves II-XII intact. Reflexes 2+ throughout. Normal tone and strength. Negative Romberg. No focal neurological deficits. Labs: Urinalysis (1 November 2024, 10:00): Specific gravity 1.015, pH 6.0, negative for protein, glucose, ketones, nitrites, leukocyte esterase. Microscopic: 0-2 WBC/HPF, 0-1 RBC/HPF. Diagnostic Imaging: Renal ultrasound (20 October 2024): Normal renal and bladder anatomy, no hydronephrosis or other abnormalities. Assessment: Alice is a 7-year-old girl presenting with persistent nocturnal enuresis and mild school-related anxiety. The enuresis appears to be primary nocturnal enuresis given her deep sleep and family history. No red flag symptoms suggestive of underlying organic pathology have been identified after initial work-up. Her anxiety is likely contributing to her overall well-being and might be exacerbated by the enuresis. Her growth and development are appropriate for her age. Plan: 1. Continue current fluid restriction and alarm therapy. Re-educate on proper alarm use. 2. Consider a trial of desmopressin for scheduled sleepovers to help with social participation. 3. Re-evaluate the effectiveness of the alarm therapy in 3 months. If no improvement, consider referral to a dedicated enuresis clinic. 4. Continue school counselling for anxiety management. Parents to encourage positive coping strategies at home. 5. Review diet, ensuring adequate fibre intake to prevent constipation, which can sometimes exacerbate enuresis. 6. Follow-up in 3 months to assess progress and re-evaluate management plan. Summary: Alice presents with primary nocturnal enuresis and associated anxiety. Given the absence of red flags and normal preliminary investigations, a conservative management plan involving continued behavioural strategies and consideration of short-term desmopressin for social events is recommended, with close follow-up to monitor progress and adjust treatment as necessary. Kind Regards, Dr. Eleanor Vance General Paediatrician cc: Parents: smith.parents@example.com