What was your plan for diagnostics and primary diagnosis?

Order Instructions

ASSIGNMENT – Please check on the CASE STUDY so you have a basis on the essay about question #5 below (Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?)

 

1. Subjective: What details did the patient or parent provide regarding their personal and medical history? When was their last visit with their specialty provider? When is their next follow-up with the specialist? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

2. Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient was presented with any growth and development or psychosocial issues.

3. Assessment: What were your differential diagnoses? Provide a primary diagnosis and, if appropriate, differentials. List them from highest priority to lowest priority and include their ICD-10 codes for the primary diagnosis. What was your primary diagnosis and why?

4. Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Did you address social determinants of health? If not, how should they have been addressed? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

5. Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? 2-page APA 7th edition essay with 3 Scientific References (this is a separate page and should be not included in the 2-page essay as this is just a list of references).

 

 

 

 

 

 

 

 

 

CASE STUDY

Well-child visit with Chronic problem (obesity)

ASSIGNMENT – Subjective: What details did the patient or parent provide regarding the personal and medical history? When was their last visit with their specialty provider? When is their next follow-up with the specialist? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

Subjective:

A 15-year-old female, coming in for a well-child exam. The patient has been generally healthy for the past year.

14-point-ROS are all negative.

Past Medical History: No, specialty or emergency care since the last visit.

Family History: No new health condition in the family, and no one died.

Social History: There are no risks for any interpersonal violence. The family and patient live in their own house. There is no issue with food security and family substance use. The patient gets their strengths with family and peers, with good community connection, and because of this patient feels protected. The patient has good school performance and good coping mechanisms with stress.

Surveillance of Development

■ Forms caring and supportive relationships with family members, other adults, and peers – Yes.

■ Engages in a positive way with the life of the community – Yes.

■ Engages in behaviors that optimize wellness and contribute to a healthy lifestyle – Engages in healthy nutrition and physical activity behaviors – Chooses safety (wearing bike helmets, using seat belts, avoiding alcohol and drugs) – Yes.

■ Demonstrates physical, cognitive, emotional, social, and moral competencies (including self-regulation) – Yes.

■ Exhibits compassion and empathy – Yes.

■ Exhibits resiliency when confronted with life stressors– Yes.

■ Uses independent decision-making skills (including problem-solving skills) – Yes.

■ Displays a sense of self-confidence, hopefulness, and well-being– Yes.

PHQ-9: 2

Immunization: UTD

 

 

ASSIGNMENT – Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

Objective:

GEN: AOx3, Normal general appearance. NAD.

VITAL SIGNS: Temp 98.1’F, RR 20, HR 93, BP 120/74

Weight: 61.3 kg. (80th percentile), Height: 163.20 cm. (60th percentile), BMI 22.91

HEENT

-Head: Normocephalic Atraumatic.

-Eyes: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus. Vision test: OU – pass.

-Ears: Normal external ears, normal TMs. Hearing test: AU – pass

-Nose: Normal nares

-Mouth and Throat: Moist mucus membranes. Normal gums, mucosa, and tonsil/palate. Good dentition.

NECK: Supple, with no masses.

CV: RRR, no murmurs/rubs/gallops.

LUNGS: clear to auscultation bilaterally, no wheezing/rhonchi/crackles.

ABD: Soft, Non-Tender/Non-Distended, NBS, no masses or organomegaly.

GU: Normal female genitalia. Tanner stage 4.

SKIN: Warm & well-perfused. No skin rashes or abnormal lesions.

MSK: Normal extremities & spine. No deformities. Normal gait. No clubbing, cyanosis, or edema. Negative Adam’s Forward Bend Test.

NEURO: Normal muscle strength and tone. No focal deficits.

 

 

 

 

 

 

 

 

 

 

ASSIGNMENT – Assessment: What were your differential diagnoses? Provide a primary diagnosis and, if appropriate, differentials. List them from highest priority to lowest priority and include their ICD-10 codes for the primary diagnosis. What was your primary diagnosis and why?

Assessment:

Primary diagnoses:

• E66.9 Obesity, unspecified

• Z00.121 Encounter for routine child health examination with abnormal findings.

• Z13.89. Encounter for screening for other disorders

• Z68.54 BMI pediatric greater/equal to 95th percentile for age

• Z72.3 Lack of physical exercise

 

Differential diagnoses:

• E10 Type 1 diabetes mellitus

• E03.9 Hypothyroidism, unspecified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSIGNMENT- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Did you address social determinants of health? If not, how should they have been addressed? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Plan:

Diagnostics:

• Hgb 15.5

• Ordered laboratory tests for Obesity: Vit. D250H, HbA1c, CMP, Lipid profile, TSH reflex to Free T4

Therapeutics: (nonpharmacological management through education/prevention discussion)

Education/Prevention

1) E66.9 Obesity, unspecified

• Discussed counseling and surveillance.

• Discussed with parents and patient proper nutrition for the patient (low sugar, low carb, & low-calorie diet). Provided parents with ChooseMyPlate.gov by the U.S. Department of Agriculture, a general guideline for the types of foods to be offered on a regular basis, including fruits, vegetables, grains, protein, and dairy.

• Discussed the higher risks of obese children [e.g., (1) high blood pressure and high cholesterol, which are risk factors for CVD; (2) impaired glucose intolerance, insulin resistance, type 2 diabetes; (3) respiratory problems such as sleep apnea and asthma; (4) joint problems and musculoskeletal discomfort; (5) fatty liver disease, gallstones, and gastroesophageal reflux; (6) psychologic stress such as depression, behavioral problems, and bullying issues at school; (7) low self-esteem and low self-reported quality of life; and (8) impaired social, physical, and emotional functioning].

2) Z72.3 Lack of physical exercise

• Discussed aerobic physical exercises daily at least 30 minutes per week.

• Discussed why time spent on sedentary behavior, such as television viewing and video/computer games, should be limited.

 

Anticipatory guidance:

• Social determinants of health (risks [living situation and food security; tobacco, alcohol, and drugs], strengths and protective factors [social connections with family, friends, childcare and home visitation program staff, and others])

• Establishing routines (adjustment to the child’s developmental changes and behavior; family time; bedtime, naptime, and teeth brushing; media)

• Feeding and appetite changes (self-feeding, continued breastfeeding, and transition to family meals, and nutritious foods)

• Establishing a dental home (first dental checkup and dental hygiene)

• Safety (car safety seats, falls, drowning prevention and water safety, sun protection, pets, safe home environment: poisoning)

Referral/Follow-up:

• The clinic will contact the mother once the laboratory test results are available.

• Scheduled next appointment: annual well-child checkup.

 

 

 

 

ASSIGNMENT – Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

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