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Week 1: Discussion Part Two No unread replies. No replies. Additional subjective answers:
Week 1: Discussion Part Two
No unread replies.
No replies.
PE:
Additional subjective answers:
Christopher D states that headaches occur one to two times a week and can last one to two days—puts hands on temple and describes headache as pulsing. He reports pain as 3 out of 5, and was not relieved with 200 mg of Ibuprofen or Naprosyn. No aura. He has been unable to continue whatever task he is working on (schoolwork, sports etc) when the headaches occur. Sometimes they upset his stomach, but he has never vomited. Sleep helps sometimes. The only thing that seems to work is distraction, so he plays Minecraft. The light from the TV hurts his eyes. No trigger identified. He wears contacts, last visit to eye doctor last month, prescription was updated and he states he sees well. He can see the board at school without difficulty.
VS: height 5'10" weight 165 pounds BP 96/60, P 78, R 14, T 98.2
General: 15-year-old Caucasian boy appears stated age in no apparent distress. Alert, oriented, and cooperative. Gait steady. Pain: 0/5 at present. Skin: skin warm, dry, and intact. Note any moles or changes. Skin color is pale pink, no cyanosis or pallor.
HEENT: Head normocep, scar left forehead from football injury three months ago
Eyes: .Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Fundoscopic exam unremarkable. Vision 20/20 corrected.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender Nose: Nares patent without exudate. Sinuses non-tender to palpation.
Throat: Oropharynx moist, no lesions or exudate. Tonsils one fourth bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline, temporomandibular joint: no clicking, non-tender.
Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses.
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally
Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.
Neuro: Cranial Nerves II-XII grossly intact. No cognitive or processing deficits
Discussion Questions Part Two:
- Identify ONE Primary with ICD 10 code diagnosis given the information in part one and part two together.
- Include the rationale and a reference for your diagnoses.
- Identify any relevant secondary diagnoses (differential diagnoses are eliminated in part two).
- Design a first-line treatment plan for your primary diagnoses based on current evidence-based journal articles.
- Further diagnostic work-up not included above
- Medications
- Referrals
- Conservative measures, including non-pharmacological and preventative measures
- Follow up- includes specific, measurable actions to be carried out at the follow up visit
