Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Follow-up for myelomeningocele (MMC)
(Specify) This will depend on the age and specific concerns of the patient. Examples include:
Infant: Management of hydrocephalus (if present), wound care, monitoring for developmental milestones.
Child: Assessment of mobility, bowel and bladder function, potential for surgical interventions, social and emotional well-being.
Adult: Management of secondary complications (e.g., latex allergies, neurogenic bladder dysfunction), sexual health concerns, long-term mobility and pressure management.
History of Present Illness:
For infants: Gestational age at birth, prenatal diagnosis of MMC (if any), presence of hydrocephalus, type of MMC repair surgery.
For all ages:
Current concerns regarding mobility, bowel and bladder function, skin integrity, developmental delays, or social participation.
History of shunt surgeries (if applicable) for hydrocephalus.
History of urinary tract infections (UTIs).
Recent hospitalizations or surgeries.
Past Medical History:
Comorbid medical conditions (e.g., Chiari malformation, tethered cord syndrome, neurogenic bladder).
History of shunt surgeries or other surgeries related to MMC.
History of UTIs or other infections.
Family History:
Family history of neural tube defects (uncommon).
Medications:
List all current medications, including:
Medications for managing hydrocephalus (shunt medications).
Medications for bowel and bladder dysfunction (e.g., anticholinergics, laxatives).
Medications for skin care (e.g., barrier creams).
Social History:
Assess impact of MMC on daily activities, school/work participation, and social integration.
Support systems available to the patient (family, caregivers, therapists).
Physical Exam:
General examination: Assess for signs of malnutrition, pressure sores, or developmental delays.
Neurological examination: Evaluate for muscle strength, sensation, reflexes, and balance depending on the patient’s age.
Skin examination: Assess for pressure sores, especially over bony prominences.
Musculoskeletal examination: Evaluate for range of motion, contractures, and ambulatory status (if applicable).
Genitourinary examination: May be performed to assess for signs of urinary retention or incontinence.
Imaging Studies:
Imaging studies may not be routinely performed at every visit. However,
X-rays of the spine: May be used to assess for bony abnormalities or hardware placement after surgery.
Ultrasound of the kidneys: May be used to assess for hydronephrosis (swelling of the kidneys) suggestive of urinary tract issues.
Urodynamic testing:
May be performed to evaluate bladder function and identify potential causes of urinary incontinence or retention.
Assessment:
Myelomeningocele: Confirmed prenatally or at birth. Specify the level of the neural tube defect.
Hydrocephalus: Present (if applicable) and being managed with a shunt system (if applicable).
Neurological function: Describe any motor or sensory deficits based on the neurological examination.
Ambulatory status: Independent ambulation, use of assistive devices (wheelchair, braces), or non-ambulatory.
Bowel and bladder function: Continent, incontinent (specify type), or requiring catheterization.
Skin integrity: Intact or presence of pressure sores (describe location and stage).
Developmental progress: Meeting age-appropriate milestones or experiencing delays (specify domains affected).
Plan:
The plan will vary depending on the age and specific needs of the patient. Some common elements may include:
Management of hydrocephalus: Close monitoring of shunt function, regular clinician visits, and potential need for shunt revisions.
Urological management: Strategies to prevent UTIs (clean intermittent catheterization if needed), medications for bladder dysfunction.
Physical and occupational therapy: To improve mobility, strength, independence with daily activities, and pressure sore prevention.