09 Jan Cardiopulmonary: Heart
Discussion Part Two (graded)
Physical Examination: Jo
Age: 5- 8/12 year-old female
Vital Signs: Height: 115 cm, Weight: 31 kg B/P:102/68, T: 97.9, HR: 90 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99% Weight percentile: 99.1%, Height percentile: 64.0%
HEENT: Head normocephalic atraumatic, hair thick and distributed throughout entire scalp; conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil. Vision remains unchanged from her first visit.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal.
Musculoskeletal: MAE
Cognitive or Behavioral: The patient was uncooperative this visit. The patient hides behind the exam table and tells her mother “no” frequently. She takes the exam paper off of the table, crawls around behind the exam table and kicks at her mother when the mother attempts to pull her out. You are able to get her out from under the table with much coaxing and a promise of a popsicle. There is difficulty to get her to stay focused while you examine her, and she asks frequent, tangential questions. She can copy a circle, square, and write her name but she has not yet learned to read or write letters beyond this.
Discussion Questions Part Two
Please add the following to your response:
Primary diagnoses and differential diagnosis with rational and the following in brief for your primary diagnosis:
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