HPI: 7-year-old male presented to clinic reporting a head pain that started three days ago. Aunt, who has custody of him, is also present at visit. He denies recent falls or injuries to head. Denies visual changes, ear pain, sore throat, nasal congestion, fever or chills. He also denies neck pain. He reports not getting headaches before. Aunt reports that she was called by the elementary school because this is his third day going to the school nurse reporting a headache. School nurse has given Tylenol, but it doesn’t seem to help. There hasn’t been a change in diet or weight. He continues to eat and drink well. Aunt reports recently getting custody of her nephew about two weeks ago. He has been having a hard time adjusting to living with her and her kids. He continues to attend the same school.
Past Medical History: Asthma, measles and mumps.
Allergies: Ibuprofen
Medications: Singulair 10 mg PO daily. “Inhaler”-does not remember the name.
Social History: Recently moved in with aunt, uncle & cousins (3 of them: 17, 15, 14). Mother/father deceased. Goes to public school, 2nd grade. No firearms, tobacco, alcohol, illicit drugs in home.
Family History: Mother and father deceased MVA, no medical history. He no siblings. Health Maintenance/Promotion: Will need to obtain records immunizations. Had measle/mumps at the age of 4.
ROS:
General. Denies fever, malaise, fatigue, and weight-loss. Denies night sweats or weight gain. Skin. Denies rashes, lesions, itching, ulcers/growths, bleeding, bruising, dryness or scales. HEENT
Head. Reports headaches and denies dizziness.
Eyes. Denies no current changes in visual acuity, dryness or pain. Ears. Denies ear pain, discharges, tinnitus and hearing loss.
Nose. Denies nasal obstruction, discharges, and bleeds.
Throat. Denies sore throat, hoarseness, dysphagia, and throat pain. Neck. Denies any neck pain.
Cardiovascular. Denies pain to the chest area, palpitations, bruits, and murmurs.
Lungs. Denies cough, wheezing, and shortness of breath. Denies any asthma sx at this time. Gastrointestinal. Denies abdominal pain, burning, acid reflux, nausea, vomiting, bloating, constipation, diarrhea, pain and straining on defecation, no blood in the stool or changes in bowel habits. Denies poor appetite.
Genitourinary. Denies dysuria, nocturia, hematuria, urinary hesitancy or frequency. Musculoskeletal: Denies weakness or joint pain.
Neurologic. Denies any history of seizures. Reports head pain like “squeezing” pain.
Endocrine. Denies temperature intolerance, polydipsia, polyuria, polyphagia, weight loss, weight gain. Psychological. Reports feeling sad at times.
Hematological/Lymphatic. Denies abnormal bruising, bleeding, and no enlarge lymph nodes.
OBJECTIVE DATA
General. A well-dressed, clean male, awake, alert, oriented X 3.
VITAL Signs (VS). Temperature: 99.0 degrees Fahrenheit, temperature route: tympanic. Heart rate: 93 bpm. Respiratory rate: 20 rpm: Blood pressure: 102/78 mm/Hg. Oxygen saturation: 100% on room air. Weight: 42 lbs. Height: 52″.
Skin. Warm and dry to touch, color and turgor good, capillary refill < 3 seconds. No rashes or lesions observed. HEENT: Normocephalic, no tenderness during palpation, no lumps, lesions, or masses, hair thick with even distribution. PERRLA, conjunctiva clear and non-icteric. Tympanic membranes gray and intact with a cone of light noted. Pinna and tragus are non-tender. Nares with no exudate. Turbinate pink and moist. Oropharynx moist, no exudates, tonsils +1. Neck full ROM. Supple, no lymphadenopathy.
Cardiovascular (CV). S1 and S2 are present. No gallops, opening snaps murmurs, or rubs. No pain with palpitation of chest wall.
Respiratory: Unlabored, bilaterally clear to auscultation. Gastrointestinal: Normoactive, bowel sounds heard in all four quadrants. Soft, flat with no distention. Non-tender, and no masses upon palpation. Genitourinary: Bladder is non-distended, no CVA tenderness.
Peripheral vascular: Pink, cap refill < 3 seconds, Extremities warm and dry and without edema. Musculoskeletal. Full range of motion. No crepitus palpated.
Neurologic. Oriented X 3 Normal gait. Good muscle strength and tone. CN II-VII tact. Psych: Flat affect, soft spoken, makes eye contact.
- The first part of the discussion board is to identify all pertinent positive and negative information.
- What other questions may you want to ask the patient?
- How will you address these findings?
- Now make a plan utilizing clinical practice guidelines for the priority diagnosis.