/planabuse*=Normal exam with no areas of concern identified.  Immunizations are up to date.  Growth and development are normal, with steady growth.  Mother has been bringing child in regularly for medical care, both acute issues and well checks.  No findings identified which raise additional concerns.
/planall*=Medication as directed.  Symptomatic therapy suggested.  Lack of antibiotic effectiveness discussed with patient. May use normal saline nasal spray as needed.  Call or return to clinic prn if these symptoms worsen or fail to improve as anticipated.
/plancolic*=Discussed colic at length.  Discussed that this is typically not due to any organic cause and is a fussiness that is due to developmental stage of the child.  Reviewed natural course of colic, that the long-term outcome is very good and that most children will be completely resolve between 3-4 months.  Discussed interventions and that there is very little data to support any intervention other than a trial of hydroxylate formula.  Discussed giving the child a calm quiet environment in which to fuss.  Discussed ensuring caregivers stay calm.  Discussed preventing of shaken babies.
/planconstipation*=Discussed at length.  Discussed common causes of constipation.  Stressed that this is typically a combination of both GI and and behavioral issues.  Accordingly, would treat with both medication and behavior.  From a medication standpoint, would use MiraLax.  Will clean out bowels with 3 capsules in 20 ounces of water or juice then continue with one capful in 8 ounces of water daily.  If needed can increase or decrease dose to achieve a soft, unformed stool.  Discussed mechanism of action, safety, and minimal risks of MiraLax, with the main risk being that excessive doses may cause diarrhea.  Discuss need to treat for extended period of time to allow both behavioral change and the GI tract to return to normal.  Also discussed behavioral approach, including regular stooling times, ideally after eating, footstool to raise knees above the level of the hips, non confrontational approach to prevent stooling from being an unpleasant experience, and ensuring plenty of fiber and water in the diet.  Would follow up in 1 month for recheck.  
/plancroup*=Discussed croup with the mother.  Discussed that this is typically part of a viral illness.  Oral corticosteroids may be effective in reducing the swelling at the level of the vocal cords, however they will not eliminate other viral symptoms including cough due to postnasal drip or pharyngeal irritation, nasal discharge, fever, or malaise.  These would need to be treated with typical symptomatic care as for any other upper respiratory infection.  Other symptomatic treatment that may improve he croup symptoms would include humid air as in the shower, or very cold air as, in Hawaii, would most likely be found by opening the freezer door and breathing cold air from the freezer.
/planearpits*=Discussed that the pit on the ear is a congenital anomaly.  These typically have no consequences unless they become infected.  Discussed the signs of infection including swelling, redness, or discharge from the area; if seen,  would bring patient into clinic.  If patient does begin having infections in that area, may consider surgical management.  
/planepipen*=Discussed the use of EpiPen.  Review technique for use, including that pants do not need to be removed for administration and that the best site for administration is the lateral aspect of the thigh.  Discussed the indications for use.  Discussed that epinephrine and adrenaline are the same thing, and that the body naturally produces epinephrine and breaks it down rapidly.  Discussed that because of this, should epinephrine be given when it is not needed, the body will rapidly process it with minimal side effects other than jitteriness.  Also discussed that epinephrine will be processed out of the body quickly and there is a potential for rebound.  Because of this stressed the importance of using the time given by use of the EpiPen to present to the nearest emergency room in case rebound does occur.  Also discussed expiration of the EpiPen and the importance of keeping an unexpired EpiPen available.  Filled out form for the EpiPen in school.
/planfeeding*=Discussed feeding schedule.  Discussed introducing single ingredient foods.  Discussed inducing single food per week and giving that food daily.  Discussed foods to avoid particularly honey.  Discussed that when introducing Fish would follow guidelines for minimizing mercury exposure.  Discussed the current guidelines do not support avoiding certain foods to minimize risk of food allergies.  Discussed need to ensure iron rich complementary foods including cereals, meats, and legumes.
/plangastro*=Clear fluids until vomiting resolves, then attempt to return to regular diet with fat and high fiber - discussed that this shown to be more effective for diarrhea than traditional BRAT diet.  Discussed that juice/soda may worsen diarrhea.   Return to the clinic if  symptoms worsen; I have alerted the patient to call if high fever, dehydration, marked weakness, fainting, increased abdominal pain, blood in stool or vomit.
/plangrowingpains*=Child does meet criteria for hypermobility.  Discussed the strong correlation between hypermobility and growing pains.  Discussed that this typically improves with age with prevalence of both growing pains and hypermobility being approximately 37% at age 4 and 4% at age 11.  In the interim, likely to be linked to higher activity days.  May use ice prior to going to bed to minimize pain.
/planheadache*=Discussed at length.  The child does have chronic headaches.  Discussed that this is typically a combination of being prone to headaches and then having headaches triggered by certain stimuli.  Discussed that there are 3 main factors in control.  First is to identify triggers and modify them if possible.  Second is to have an effective plan for treatment of headache when one arises.  Third is to discuss controller therapy is indicated.  For the first, asked family to keep a headache diary as this may show patterns that we just to identifying workers.  For the second, stressed the importance of treating early.  Discussed typical early signs of headache with the goal of recognizing headaches more quickly.  
/planinhaler*=Discussed that the inhaler should be as effective as the nebulizer if used appropriately.  Plan to arrange asthma education for better use of the inhaler as this should provide him with relief that is faster, more portable, and not in the electricity compared to the nebulizer.
/planinsomnia*=Discussed behavioral approach at length, including turning bright lights and in the morning, keeping wake up time constant, regular bedtime routine for approximately 30-60 minutes prior to going to bed, absence of TV or or video games for 30-60 minutes before going to bed, not having a TV in the bedroom, not using bed for anything other than sleep, and upon development of insomnia, getting out of bed to prevent an association between anxiety over sleep and laying in bed. 
/planmolluscum*=Discussed that molluscum are caused by a virus, and that the final resolution depends on the immune system handling the virus.  Also discussed that there are multiple different treatments to reduce the lesions in size, and that these may cause some irritation and speed up the immune response to the virus at the heart of the problem.  Discussed that the best data is for curettage.  However, discussed that with no treatment, spontaneous resolution rate is high.  Discussed that a period of observation is very appropriate if none of the lesions are causing problems as allowing time for spontaneous resolution may well be the least invasive and least traumatic approach.
/planmurmur*=Discussed innocent murmur.  Discussed that there is no need for limitation of activities.  No need for SBE prophylaxis.  No need for additional followup.
/plannoflu*=Parents declined flu shot.  Discussed risks and benefits of vaccination vs. not vaccinating.  Discussed recommendation for annual vaccination.  Discussed hours of operation of immunization clinic for walk-in's should parent reconsider.^
/planOME*=Discussed that the fluid behind the tympanic membrane is common after an ear infection or a cold.  Discussed that the fluid is not an infection.  Discussed that many treatments have been tried in the past to resolve the fluid more quickly, but none of them have been found to be effective.  Discussed that the normal course is that this will typically resolved within about 3 months.  If the patient is seen within the next 3 months, would ask the provider to check the affected ear.  If the fluid is resolved at that time, no further followup is needed.  If the child is not seen in the next 3 months, or if the fluid does not resolve, would make a followup appointment in about 3 months for recheck of the ear.  If the fluid is still present at that time, may discuss referral to ENT.
/planpinkeye*=Plan to treat with Tobrex.  Discussed dosing 3-4 times a day for 5 days.  Discussed good hand washing.  Contagiousness will start to decrease upon starting treatment, and will have no restrictions due to contagiousness within 24 hours.
/planpreprocedure*=Cleared for procedure.  Gave parent written copy of pre-procedure physical form as backup to this note.  Discussed that if condition changes between now and date of physical, parents are to contact sedation team/ordering physician to discuss whether procedure should proceed as planned or be rescheduled.
/planreflux*=Given greater than average weight gain, reflux appears to be primarily due to overeating.  Congestion is secondary to reflux.  Discussed that given good weight gain, at this point would not consider medication as a primary treatment for this condition.  Instead, behavioral approach is likely to control symptoms very effectively.  Discussed having him a slight angle with the head above the stomach to minimize the degree of reflux happening at night.  Would also have him in or a minimum of 30-60 minutes after eating to minimize reflux.  Also discussed over eating; would recommend that mother try to slow down feedings by burping and distracting child towards the end ofnormal duration of feeding to attempt to allow him to eat based on sense of satiety rather than complete fullness.  If this is not completely successful, the next avenue him of approach would be attempting elimination of pending fluid from mother's diet, particularly caffeine, chocolate, mint, and spicy foods.
/planrice*=Discussed supportive care.  Would use ibuprofen for pain.  Discussed that ibuprofen typically works as well as Tylenol with Codeine for musculoskeletal injuries.  Would apply ice 10-15 minutes at a time 3-4 times a day for the next several days to reduce swelling.  Would keep area elevated above the level of the heart to decrease swelling. 
/planringworm*=Plan to treat twice daily and observe.  Expect that improvement should be noted within the next several days.  Discussed treating it outside the margins of the current rash, massaging cream into the skin, and treating for 48 hours past full resolution.
/planseborrhea*=Discussed treatment options including 1) observation with no treatment, 2) applying mineral oil or baby oil to scales and allowing it to sit for 5-10 minutes, then combing through with fine tooth comb, 3) for severe cases, using selenium sulfide shampoo such as Selsun Blue.  However cautioned that this may irritate the eyes and should only be used for severe cases.  Discussed natural course of seborrhea. 
/plansinusitis*=Discussed that this should be causing some clinical improvement in 2-3 days.  If no improvement in 4-5 days, plan followup as may need a different antibiotic.  If symptoms improve with antibiotic, but the symptoms recur once antibiotic is discontinued, would also follow up as may need a longer course of the same antibiotic.
/plansleepterror*=Discussed sleep terrors as a member of the parasomnia family.  Discuss their relationship to confusional arousals and sleepwalking.  Discussed that this is a very common occurrence in young children.  Discussed that the most common trigger of these is poor sleep or a disrupted sleep routine.  Discuss treatment from several perspectives.  During an episode, would attempt to minimize interaction with the child as this may make the child more agitated.  During a series of episodes, would wake the child one to 2 hours after awakening for a brief period as this has been shown repeatedly to work very well to prevent that night's episodes.  In general, would concentrate on a regular sleep routine and good quality sleep.
/plansprain*=Discussed that no fracture was seen.  Discussed that sprains are injuries to the ligaments, and can be quite painful and take prolonged periods to heal.  Stressed the importance of allowing the leg to heal and avoiding painful activities.  Would treat with ibuprofen 3 times a day for the next 3-5 days then as needed for pain control.  Discussed appropriate dose.  Would keep the injured area elevated above the level of the heart to minimize swelling.  Would also apply ice 3-4 times per day for 10-15 minutes per application.  Also discussed compression wrapping and the use of crutches.
/planstoolchange*=History is not consistent with constipation.  Reassured mother that child is not constipated and does not need to be treated for constipation.  Discussed normal change in stooling habits at around one month of age and that many children will decrease the number of stools significantly at this age.  Discussed that normal stooling at this age may be anywhere from 5-6 stools per day to one to 2 stools per week and that as long as the stool is soft, child is not constipated
/plantb*=Discussed tuberculosis with parents.  Given positive PPD and normal chest x-ray with absence of symptoms, would make the diagnosis of latent tuberculosis.  Discussed that the best course of action is to treat this with 9 months-270 doses-of isoniazid.  Discussed that latent tuberculosis is very common with approximate 2 billion individuals affected worldwide.  Discussed that latent tuberculosis is not contagious and is not symptomatic as the individuals immune system is keeping the infection contained.  However, would recommend PPD's for family members as no source of infection was found, and other family members may have been exposed at the same time.  Discussed that the pills of isoniazid are typically better tolerated than the liquid.  Discussed that common side effect is include mild GI upset which is typically self-limited.  Discussed that the elevations in liver enzymes are not typically seen in children.  Discussed that some paresthesias can be seen and described with these would feel like.  Discussed that these can be treated with the addition of vitamin B6 and asked the parents to contact me if these are noted as they will typically be within the first several weeks of initiating treatment.  Discussed that we will need to follow up monthly for the first several months.  Discussed that at the end of therapy we will write a letter documenting completion of treatment and stating that PPDs should not be done in the future.  Answered parents questions and asked them to bring  any additional questions that they may think up to the next medication check so we can ensure that all their questions are answered.
/plantoddlerdiet*=Discussed toddler diet.  Discussed that normal toddler will eat irregularly with significant consumption on some days and very little consumption on others.  Toddlers also typically vary significantly in how well they will eat certain foods, eating a certain food with just a one-day and refusing to another.  Discussed offering a well-balanced diet.  Discussed repeated offerings of foods to note familiarity with foods.  Discussed not allowing children to fill up on milk, juice, or junk foods.  Discussed and not making eating a direct conflict but rather offering choices(such as "would you rather have green beans or broccoli tonight" or "If you want seconds of X., you need to eat some of Y.").  Also discussed that when planning meals, foods that the child will eat should be included in the planning; however if the child does not eat well, additional foods should not be offered until something is found that the child will eat, as this will teach the child to view parents as short order cooks.
/planuri*=No sign of otitis media or of lower respiratory tract involvement.  Discussed probable viral cause.  Discussed that most cough and cold medicines are not effective under 4-6 years of age.  Treatment as ordered.  Symptomatic therapy suggested of fluids and rest.  Lack of antibiotic effectiveness discussed with patient. Patient may use normal saline nasal spray as needed. Call or return to clinic as needed if these symptoms worsen or fail to improve as anticipated.
/planvulvitis*=Given her age, absence of history of prior UTIs, appearance of erythema on the vulva, and normal urinalysis, the most likely diagnosis is nonspecific vulvitis.  The absence of drainage suggests that there is no vaginitis.  Will send urine culture to confirm; however in the absence of any positive results at this point would not start antibiotics.  Would recommend the use of vinegar in baths at a ratio of 1/2 cup per 13 gallons as well as application of Vaseline to the vulvar mucosa.  Reviewed the application specifically to the vulvar mucosa and not the perineum as was done when she had diaper rashes.  Also discussed prevention, including double checking underwear and swimsuits to nature that they are not excessively tight, reviewing wiping technique this Peart to kill early directed at preventing pooling of urine, and hydration to reduce concentration of urine and subsequent irritation due to the urine.    If the urine culture is positive, will call and start antibiotics.  Best contact number is 
/planwarts*=Discussed that warts are caused by a virus, and that the final resolution depends on the immune system handling the virus.  Also discussed that there are multiple different treatments to reduce the wart in size, and that these may cause some irritation and speed up the immune response to the virus at the heart of the problem.  Would use salicylic acid applied topically daily and covered with an occlusive dressing.  Would change this daily after soaking.  Every 2-3 days, would pare down the outer aspect of the wart with a file razor or emery board.  The best time to pare down to the wart is immediately after soaking.  Would continue this and expect see significant improvement over the next several weeks.  Did discuss that as the root problem is a virus, while this treatment may be successful in removing the wart, if the virus persists, the wart may return.
/planweight*=Discussed weight at some length.  Areas of discussion included increasing physical activity, limiting constant in front of the screen as, such as computer, television, and video games, decreasing the amount eaten per meal, increasing the amount of fruits vegetables and gr, ensuring that meals are not skipped, discussing the calories in drinks particularly juice and pop, and the technique of splitting the plate of the quarters, then filling and one quarter with protein, one quarter with starches, predominantly whole grains, and one half with fruits and vegetables.
/planwheeze*=Discussed wheezing in a child under 3 years of age.  Review the possible causes, including postviral, constitutionally small airways, and possible asthma.  Also discussed how difficult it it may be to distinguish between these 3 at this time.  Given the presence of wheezing, however, would start albuterol at this time to see if any benefit is noted.  If no benefit is seen from albuterol, unlikely to go on to develop asthma.  However response to albuterol may not predict future development of asthma.  Reviewed proper technique of use of both metered-dose inhaler and spacer.