Herzing NU632 Unit 12 Discussion Latest 2021 February

NU632 Healthcare of Infants, Children, and Adolescents

Unit 12 Discussion

Instructions:

Please evaluate the subjective and objective information provided to you in the file below.

The first part of the discussion board is to identify all pertinent positive and negative information.

Would there be any other information you would want to obtain?

Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.

Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis, as well as expected health promotion and expected developmental milestones.

Be sure to include APA in-text citations and provide full reference citation at the end of the discussion

NU632 Unit 12 Discussion Case

C.C. “I’m so thirst all the time.”

HPI: 14 y.o. F presents to clinic with grandfather for what she believes is dehydration. She reports symptoms started a week ago with constantly being thirst. She noticed that she was going to the bathroom more than normal too, but she thought it was because she was drinking more. She denies burning or blood with urination. She is having some abdominal pain but reports more like cramping.

She has also been experiencing some nausea but no vomiting. Denies diarrhea, fever or chills. She is currently drinking a bottle of Gatorade in office. Grandfather reports her being sick a few weeks ago but she hasn’t gotten better since then. He reports her looking tired.

Allergies: None.

Current Mediation: None.

Health Maintenance: Up to date on all immunizations with the exception of flu vaccine.

Family History: Mother - HTN, diabetes. Father – No medical history. Maternal grandfather deceased at 61 due to heart attack and maternal grandmother has diabetes and HTN. Paternal grandfather HTN, CAD.

Social History: Denies drug, ETOH or illicit drug use. She is a high school freshman. She is unemployed.

She is not sexually active.

Exercise & Diet: Patient does have a regular exercise routine. Eats healthy variety of foods.

Safety Measures: Wears seat belt. No firearms in the home.

ROS:

General: Overall, she reports feeling okay, has reported some weight loss but no changes in appetite. Has had increase thirst. HEENT: Denies headaches, sinus problems, dental problems, oral lesions, hearing loss or changes, nasal congestion. Denies visual changes, diplopia, and dry eyes. Denies ear pain, changes in hearing, tinnitus. Denies sore throat, difficulty swallowing, dental pain. Denies neck pain or stiffness. Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema. Denies cough, SOB on exertion, difficulty breathing, wheezing. GI: Denies, vomiting, dysphagia, loss of appetite, bloating, diarrhea, or change in bowel habits. Has had some abdominal cramping with nausea. Has not achieved menarche.

GU: Denies sexually active. Denies dysuria but is having urinary frequency.

Hem: Denies bruising or bleeds easily or history of any blood transfusions.

MSK: Patient denies joint pain, swelling, muscle pain or cramps, neck pain or stiffness, or changes in ROM.

Neuro: Denies weakness, numbness, tingling, memory difficulties, involuntary movements or tremors

Endo: Denies cold or heat intolerance, having increase in thirst and some weight loss (about 10 lbs).

Psych: Patient denies mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, and exposure to violence, or excessive anger.

Objective:

Physical Examination (PE):

VS: BP: 102/60, HR: 76, RR: 18, Temp 98.5, weight: 109, height: 63inches

Gen: General Appearance: Affect and facial expression appropriate to situation, patient well-nourished  and appears stated age. No acute distress noted. Ambulating without assistance.

Skin: Skin warm, dry and intact. No lesions present. Skin tenting.

HEENT: Skull round with symmetrical protuberances, nontender upon palpation, hair evenly distribution, and scalp clean and free of lesions. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.

Sunken eyes. Extraocular movements intact. Ears appearance within normal limits. Hearing is intact.

Nose: appearance of nose normal with no mucous, inflammation or lesions present. Nares patent.

Septum is midline. Mouth: pink, dry, tacky mucous membranes. No missing or decayed teeth. Neck: Had a supple and no lymphadenopathy CV: S1, S2. Regular rate and rhythm. Respiratory: Even and unlabored. Clear to auscultation bilaterally without wheezes, rales, or rhonchi. Abd: soft, flat, nontender without masses or hepatosplenomegaly. Bowel sounds active x 4. No bruits.

GU: No bladder tenderness upon palpation, no distention noted. No CVA tenderness.

PV: No edema. Capillary refill < 2 sec bilaterally. MSK: Normal ROM, joint stability normal in all extremities, no tenderness to palpation. No scoliosis noted.

Neuro: Grossly alert and oriented x3, communication ability within normal limits, attention and concentration normal. Sensation intact to light touch, gait within normal limits

Psych: Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Patient appears to be happy/content.