General Intake - Sleep Pediatric

Subjective:
Chief Complaint:
Identification: Thank you for asking me to see Olivia, 13, for evaluation of sleep disordered breathing. She is accompanied by her parent. Thank you for the kind referral. I will summarize history for my records. Chief Complaint: Sleep disordered breathing.

History of Present Illness:
Olivia, a 13-year-old female, presents with a history of snoring and restless sleep. According to her mother, these symptoms have been present since toddlerhood and occur nightly. Olivia is described as being restless and sweaty during sleep but does not appear to struggle to breathe. There is no history of specific questions noted in the referral from the family doctor. Olivia has a history of epilepsy, with prior evaluations including an electroencephalogram and imaging studies. She has been referred to an otolaryngologist in the past, but the family reports that no appointments were attended. No other associated symptoms or recent changes in health were reported during the encounter.

Sleep History:
Sleep Habits/Sleep Hygiene:
- Timing of going to bed: Not mentioned
- Sleep schedule consistency (weekdays vs. weekends): Not mentioned
- Time to fall asleep: Not mentioned
- Nighttime awakenings (WASO): Not mentioned
- Morning wake-up time: Not mentioned
- Total sleep duration: Not mentioned
- Feeling rested in the morning: No
- Pre-bedtime routine: Not mentioned
- Daytime naps: Not mentioned
- Sleep Environment: Not mentioned
- Sleep Hygiene: Not mentioned

Parasomnia Symptoms:
- Sleep walking (somnambulism): Not mentioned
- Sleep talking (somniloquy): Not mentioned
- Night terrors: Not mentioned
- Sleep paralysis: Not mentioned
- Confusional Arousals: Not mentioned

Associated Signs & Symptoms:
- Snoring: Yes, nightly since toddlerhood
- Breathing Issues: No struggle to breathe during sleep
- Nonrestorative sleep (waking up tired): Yes
- Morning headaches: Not mentioned
- Excessive daytime sleepiness: Not mentioned
- Irritability: Not mentioned
- Restlessness: Yes, restless during sleep
- Nocturia: Not mentioned
- Bedwetting: Not mentioned

Development:
- Developmental Milestones: Not mentioned
- Appetite: Not mentioned
- Growth: Not mentioned

Past Medical History:
Pregnancy and Birth History: Not mentioned
Significant Medical Conditions: Epilepsy
Previous Sleep Evaluations: Not mentioned
Past hospitalizations: Not mentioned
Allergies: Not mentioned
Current medications: Not mentioned
Pertinent Negatives: No ENT visit despite referral in 2022

Immunizations:
Up-to-date

Past Psychiatric History:
Previous Diagnoses: Not mentioned
Previous Treatments: Not mentioned

Past Surgical History:
Previous Surgeries: Not mentioned

Family History:
Family History of Sleep Disorders: Not mentioned

Social History:
School Performance: Not mentioned
Behavioral Issues: Not mentioned
Screen Time: Not mentioned
Family Dynamics: Not mentioned

The Review of Systems:
Constitutional:
Fatigue: Not mentioned
Weight changes: Not mentioned
Appetite changes: Not mentioned
Behavioral changes: Not mentioned
General malaise: Not mentioned
ENT:
History of trauma: Not mentioned
Deviated septum: Not mentioned
Tonsillar/adenoid enlargement: Not mentioned
Ear infections: Not mentioned
Sinus problems: Not mentioned
Respiratory:
Wheezing: Not mentioned
Shortness of breath: Not mentioned
Cough: Not mentioned
Exercise intolerance: Not mentioned
Cardiovascular:
Palpitations: Not mentioned
Chest pain: Not mentioned
Cyanosis: Not mentioned
Swelling: Not mentioned
Congenital heart defects: Not mentioned
Arrhythmias: Not mentioned
Gastrointestinal:
Gastroesophageal reflux (GERD): Not mentioned
Constipation: Not mentioned
Abdominal pain: Not mentioned
Celiac disease: Not mentioned
Halitosis: Not mentioned
Genitourinary:
Dysuria: Not mentioned
Urgency: Not mentioned
Pelvic pain: Not mentioned
Musculoskeletal:
Growing pains: Not mentioned
Muscle cramping: Not mentioned
Joint pain: Not mentioned
Stiffness: Not mentioned
Injuries: Not mentioned
Integumentary:
Itching: Not mentioned
Rashes: Not mentioned
Eczema: Not mentioned
Hives: Not mentioned
Dry skin: Not mentioned
Dermatitis: Not mentioned
Infections: Not mentioned
Wounds or ulcers: Not mentioned
Neurological:
Headaches: Not mentioned
Seizures (345.90): Yes
Tics or tremors: Not mentioned
Hyperactivity: Not mentioned
Developmental delays: Not mentioned
Psychiatric:
Anxiety: Not mentioned
Depression: Not mentioned
ADHD: Not mentioned
Nightmares: Not mentioned
Fear of the dark: Not mentioned
Stress: Not mentioned
Obsessive-Compulsive Disorder (OCD): Not mentioned
Behavioral issues: Not mentioned
Autism Spectrum Disorder (ASD): Not mentioned
Bipolar Disorder: Not mentioned
Endocrine:
Thyroid: Not mentioned
Diabetes mellitus: Not mentioned
Adrenal disorders: Not mentioned
Puberty-related hormonal changes: Not mentioned
Obesity: Not mentioned
Hematologic/Lymphatic:
Anemia: Not mentioned
Swollen, painful lymph nodes: Not mentioned
Frequent infections: Not mentioned
Hemophilia: Not mentioned
Easy bruising: Not mentioned
Bleeding: Not mentioned
Allergic/Immunologic:
Food allergies: Not mentioned
Seasonal allergies: Not mentioned
Psychiatric:
Low mood: Not mentioned
Tearfulness: Not mentioned
Anxiety: Not mentioned
Signs and symptoms of mania or hypomania: Not mentioned

Allergies:
No known drug allergies, food allergies, or environmental allergies were reported during the encounter. The patient did not disclose any hypersensitivity to medications, foods, or environmental factors. There was no mention of allergies to anesthetic agents, adhesives, or latex.

Current Medications:
The patient is currently taking valproic acid and a medication referred to as 'Xerontin' for the management of epilepsy. The exact dosage, frequency, and route of administration were not specified during the encounter. There was no mention of over-the-counter medications, supplements, or other prescribed medications. The patient and her family did not report any side effects or concerns related to her current medication regimen. Additionally, there was no indication of non-adherence or neglect in medication management.

Objective:
Physical Examination:
Vital Signs and Measurements:
Temperature: Not mentioned
Pulse: Not mentioned
Blood Pressure: Not mentioned
Respiratory Rate: Not mentioned
Oxygen Saturation: Not mentioned
Weight: Not mentioned
Height: Not mentioned
BMI: Not mentioned
Head Circumference: Not mentioned

Physical Examinations:
Constitutional:
Appearance: Not mentioned
HEENT:
Head: Not mentioned
Eyes: Not mentioned
Ears: Not mentioned
Nose: Not mentioned
Throat: Not mentioned
Neck:
Not mentioned
Cardiovascular:
Heart sounds: Not mentioned
Respiratory:
Inspection: Not mentioned
Palpation: Not mentioned
Percussion: Not mentioned
Auscultation: Not mentioned
Abdomen:
Not mentioned
Extremities:
Not mentioned
Neurological:
Cranial nerves: Not mentioned
Strength: Not mentioned
Sensation: Not mentioned
Reflexes: Not mentioned
Coordination: Not mentioned

Evaluation:
Sleep Study: Not mentioned
Polysomnography Results: Not mentioned
Actigraphy: Not mentioned

Test Results:
Laboratory Tests: Not mentioned
Imaging Studies: Not mentioned

Assessment:
Problem:
Obstructive sleep apnea (327.23)
 Restless sleep (780.52)
 Childhood epilepsy with generalized seizures, stable (345.90)
 Asthma with air trapping (493.90)
 Dental caries (521.0)
 Ectopia of the left cerebellum (Q04.3)

Impression:
Obstructive sleep apnea (327.23)
 Restless sleep (780.52)
 Childhood epilepsy with generalized seizures, stable (345.90)
 Asthma with air trapping (493.90)
 Dental caries (521.0)
 Ectopia of the left cerebellum (Q04.3)

Differential Diagnosis:
1. Obstructive Sleep Apnea (327.23)
2. Primary Snoring (786.09)
3. Restless Leg Syndrome (333.94)
4. Sleep-Related Breathing Disorders (780.57)

Diagnosis Rational Discussion:
The diagnosis of snoring and restless sleep (780.57) is supported by the patient's history of nightly snoring since toddlerhood, restlessness during sleep, and nonrestorative sleep. The absence of breathing struggles during sleep and the lack of ENT evaluation despite a referral in 2022 are also considered.

Plan:
The patient has been referred to an Ear, Nose, and Throat (ENT) specialist for further evaluation of snoring and the possibility of airway obstruction. The family has been educated on the importance of attending the ENT follow-up to ensure proper assessment and management of the condition. 

Currently, no medications, behavioral therapy, or lifestyle modifications have been prescribed. A follow-up appointment has been scheduled to review the findings from the ENT evaluation and to discuss the next steps in the patient’s management plan.