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NURS/NRNP (i-Human) – Early Identification and Management of Autism Spectrum Disorder, Walden University, i-Human case analysis and SOAP note A+ Graded

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This document covers a full i-Human case analysis focused on the early identification and management of Autism Spectrum Disorder (ASD) in a pediatric outpatient setting. It includes a comprehensive HPI, physical exam, differential diagnoses, diagnostic plan, final diagnosis, treatment plan, follow-up, and a detailed SOAP note aligned with Walden University NURS/NRNP course requirements. The case emphasizes evidence-based screening tools, early intervention strategies, and family education relevant to pediatric developmental and behavioral health.

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WEEK #7 I-HUMAN CASE ANALYSIS FOR WALDEN
UNIVERSITY – FOR A 22 MONTHS DAUGHTER WITH
DIFFICULTY IN MAKING FRIENDS/ SOCIAL SECURITY
CONCERNS (EARLY IDENTIFICATION AND MANAGEMENT OF
AUTISM SPECTRUM DISORDER) LOCATION: OUTPATIENT
CLINIC CAPABILITIES Graded A+




Walden University
Course: NURS / NRNP (i-Human)
Encounter Type: Outpatient Pediatric Clinic

,Case Title

Early Identification and Management of Autism Spectrum Disorder
Chief Concern: “My daughter doesn’t interact with other children and prefers to
play alone.”




1. General Case Information

• Patient: Female child
• Age: 3 years
• Caregiver: Mother
• Setting: Outpatient pediatric clinic
• Reason for Encounter: Developmental and behavioral concerns related to
social interaction and play
• Source of History: Mother (reliable historian)




2. Chief Complaint (CC)

“My daughter doesn’t interact with other children and prefers to play alone.”

, 3. History of Present Illness (HPI)

The patient is a 3-year-old female brought to the outpatient clinic by her mother
due to concerns about delayed social interaction and atypical play behaviors.
The mother reports that since approximately 18–20 months of age, the child has
shown minimal interest in interacting with peers and consistently prefers solitary
play.

The child does not initiate play with other children at daycare and often plays
repetitively with toys, particularly lining them up or spinning wheels. She has
limited pretend play and becomes upset when routines are disrupted. The mother
notes poor eye contact, limited response to her name, and infrequent use of
gestures such as pointing or waving.

Speech development is delayed; the child uses single words inconsistently and
does not form two-word phrases. She does not engage in reciprocal conversation
and rarely imitates others. There is no history of regression of previously acquired
skills.

The mother denies seizures, loss of motor milestones, fever, trauma, or chronic
illness. No concerns regarding hearing or vision have been formally evaluated.

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