Please evaluate the subjective and objective information provided to you in the file below.
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.
Be sure to include APA in-text citations and provide full reference citation at the end of the discussion
Unit 4 Discussion Case
HPI: M.M. is a 5 y.o. F who present to HU clinic with her mother for nightmares. She was recently
evaluated at the clinic 1 month ago for her 5-year-old well child checkup. Developmental, behavior
showed no concerns at that visit. Mother reports nightmares started 3 months ago but now they are
occurring more frequently at least twice per week. Mother reports M.M. going to bed around 9PM and
normally by 11PM she is up screaming, confused and clammy.
Mother and father are unable to get her
to calm down during these episodes. M.M. will eventually calm down and fall back asleep. She usually
wakes up at 6:30 AM to start to get ready for school. Mother denies any recent changes in her home
life, she did start kindergarten and also a soccer league (practice twice a week for an hour with 30-
minute games on the weekend).
M.M. reports not remembering these episodes. She reports still
enjoying school and has made a new friend name “Jaden.” They are in class together and on the same
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: Immunizations are up to date including this season’s flu vaccine.
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, 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.
VS: Temperature: 99.2 F, 99/59, HR: 89, RR: 22, 100% on RA, Ht: 55 in (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.
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 B, C, M, L. Mild erythema and swelling gingivae. 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.
MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.