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Discussion 3 – Pediatric Evaluation

Discussion 3 – Pediatric Evaluation

Sample Answer 

Discussion 3 – Pediatric Evaluation

Pediatric Evaluation

The patient presents several encouraging social, medical, and physical information from the HPI, PMH, and social history. The review of systems also indicates that the 5 y.o. F tested negative on all the tests conducted. The objective observations at the clinic also indicate that the girl is normal. However, the parents present some information that could be worrying that could affect the child’s social life if not addressed at an early age. First, the father reports that he vapes in the house. Vaping in the home, especially in the presence of infants, exposes the developing lungs and brains of the children to a high concentration of nicotine, which hinders normal weight gain and lung growth (Wang, Ho, and Lam, 2011). Additionally, when M.M. sees her parents using drugs and alcohol in her presence, her chances of going on to use e-cigarettes at a later stage in life or becoming alcoholic are heightened (Hovell et al. 2009).

The possible actual diagnosis for the child based on the findings could be based on the findings of the social history of the parents. Therefore, to examine the patient, she should be tested for shortness of breath, coughing, or chest pain. The body temperature should also be measured to test for fever. These should be measured to ensure that the child does not present any of the signs or symptoms of vaping as well as the signs of ingesting high levels of nicotine.

Since the child is reported to love physical education in school, parents and teachers should encourage physical activity at home and school. Additionally, parents should develop smoking cessation programs to help the child grow and avoid developmental milestones related to vaping (Oppenheim et al, 2016). Finally, family and child nutrition should be encouraged in place of medication, such as Disney Princess Gummy Vitamin and allow her to acquire vitamins naturally from her diet.

References

Hovell, M. F., et al. (2009). Counseling to reduce children’s secondhand smoke exposure and help parents quit smoking: a controlled trial. Nicotine & Tobacco Research11(12), 1383-1394.

Oppenheim, J., et al. (2016). Launching forward: The integration of behavioral health in primary care as a key strategy for promoting young child wellness. American Journal of Orthopsychiatry86(2), 124.

Wang, M. P., Ho, S. Y., & Lam, T. H. (2011). Parental smoking, exposure to secondhand smoke at home, and smoking initiation among young children. Nicotine & Tobacco Research13(9), 827-832.

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Question 


Discussion 3 – Pediatric Evaluation

Discussion Prompt:

  • 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.
  • Document any other information you would want to obtain?
  • Create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
  • Next, create a plan utilizing clinical practice guidelines for the priority diagnosis, as well as expected health promotion and expected developmental milestones.
  • Include APA in-text citations & provide at least 2 full scholarly reference citation at the end of the discussion. Journals and websites must be cited appropriately.

    Discussion 3 – Pediatric Evaluation

    Discussion 3 – Pediatric Evaluation

***File below:

 NU632 Unit 3 Discussion Case

C.C. 5-year-old well child visit

HPI: M.M. is a 5 y.o. F who present to HU clinic with her father for her 5-year-old well child visit.  She reports liking school and has made some friends.  Her favorite part of the school day is “PE.”  At present time she reports no complaints.  Father reports no concerns with development, behavior or nutrition.

PMH: Born at 39 weeks’ gestation via cesarean section for being in a breech position. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant was breastfed. Allergies: No known drug allergies Medications: Disney Princess Gummy Vitamin Social History: The child lives with her mother and father who have been married for 2 years. Both parents work full-time. She started public school two months ago which is full day kindergarten. Father Vapes in the home.  Both parents report social drinkers on the weekend, “couple of beers with dinner.” There are no firearms in the house. Family History: Mother and father deny any significant medical history.

Health Maintenance/Promotion:

Review of Systems General: Denies any concerns, unexplained fevers, or growth and developmental concerns. Skin: Denies any rash, lesions, or concerns with eczema. Head: Denies headache, trauma or falls. ENT: Denies any concerns with ears, nose, or throat. Neck: Denies pain with ROM neck. Denies masses or lumps.  CV: Denies any chest pain, cyanosis, heart racing or sweating.  Lungs: Denies any cough, congestion, wheezing, or difficulty breathing.GI: Denies food intolerances. Denies weight loss, nausea, vomiting, constipation or diarrhea.GU: Negative for burning or blood in urine. Musculoskeletal: Denies pain, trauma, and numbness.  Neurological: denies changes in senses.  Psych: Denies difficulty concentrating, tearful episodes, anxiety or seclusion.  Endocrine: Denies increase thirst or urination.  Hematologic: Denies bruising or bleeding.

Objective VS: Temperature: 98.1 F, 107/62, HR: 66, RR: 20, 100% on RA, Ht: 55in (93.52%), Wt.: 97 lbs. (98.3%), BMI: 22.54(97%).General: Well developed, well-nourished and hydrated, no apparent distress. Appropriate dressed. Skin: No evidence of rash or lesions. Head: Normocephalic. Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally. ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Dental caries on B, C, M, L.  Oropharynx: normal mucosa, palate, and posterior pharynx. Neck: Supple and no lymphadenopathy.

CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally. Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes. Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed.GU: Normal female genitalia. Tanner stage 1. MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.

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