Discussion Part Two (graded)
Physical Examination Jo:
V/S: Height: 109 cm, Weight: 27 kg, B/P:102/60, T: 98.2, HR: 88 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99%
General: Cooperative, talkative, appropriate; HEENT: head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; fundoscopic exam unremarkable; vision by snellen exam 20/50 in her left eye, 20/40 in her right, and 20/30 together; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 1/4 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.
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; GU – labia majora and minora intact, no erythema or discharge.
Musculoskeletal: MAE. Able to do deep knee bends; hop on one foot on either leg, able to balance on each leg for 10 seconds.
Cognitive Development: Able to state name and age; can write her own name; able to recall three friends names; knows all colors and can count to 13; dresses herself and has control of bowels and bladder; verbal throughout exam; all of speech clear and recognizable.
Physical Examination Riley:
V/S: Height: 83cm, HC: 48cm, Weight: 12.5 kg, B/P: 88/52, T: 97.8, HR: 112 BMP/reg., Resp: 24, reg, non-labored, SpO2: 99%
General: Active and cries throughout exam; fights being held for exam; calms quickly once exam is over. HEENT: Head normocephalic atraumiatic, hair thick and distributed throughout entire scalp; Conjuctiva clear, non-icteric, PERRL; unable to complete fundoscopic exam; tympanic membranes intact with scant clear fluid posteriorly bil; EAC unremarkable; pinna/tragus w/o tenderness; nares patent, mucosa pale, sl. edema in inferior and medial turbinates bil, scant clear rhinorrhea; pharynx with mild posterior cobblestoning, tonsils 2/4 bil; primary tooth eruption to include all incisors, canines, and first molars on the lower, upper incisors and first molars; no loose teeth; some yellow discoloration noted to top left central incisor; oral exam unremarkable; neck supple with mild anterior cervical lymphadenopathy bil; thyroid small, firm, equal bil.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal, intact bil radial and pedal; GU—both testes present.
Musculoskeletal: MAE; able to run in the room and climb on the exam table.
Cognitive Development: Verbalizes five words: mama, dada, drink, juice, and no; does babble; majority of speech unintelligible; able to feed self; not potty trained.
Physical Exam Kayla:
V/S: Height: 160 cm, Weight: 67 kg. B/P: 140/76, HR: 82, T: 98.7, Resp: 16, SpO2: 97%
General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam; skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent with pink, moist, intact inferior and medial turbinates; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy or thyromegaly.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.
Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without discharge or tenderness. No masses or tenderness upon palpation
Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal
External Genitalia: Mons intact with normal hair distribution, labia majora, minora, clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen.
Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or discharge.
Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile without tenderness.
Uterus: small, firm, pear shaped, midline, smooth, mobile, and non-tender uterus non-tender uterus. Adnexae: present, smooth, non-tender.
Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, negative for WBCs, nitrites, leukoesterase, RBCs, glucose, and ketones.
Discussion Questions Part Two:
For the patients you have chosen what are your primary and secondary diagnoses now with ICD-10 codes with rationale?
What other diagnostics, preventive screenings, or preventive health actions are you considering for your patients at this time and why?
* Remember to include your evidenced-based reference for your rationale and each step of your plan.
Since this visit is a well-child visit, please pick one area of anticipatory guidance appropriate for either Jo or Riley. Be sure to go in and read other’s posts. Cite all sources of information. List the following with clear headers:
Topic
Definition
Target age range
Educational points to be made to the parent concerning this area
