NR602 Discussion Week 5 part 1 and 2

PBL Case Discussion: Issues in
Growth and Behavior Part One (graded)

Today you note that Kayla is back
with Jo for behavioral issues.

HPI: Kayla (mom) is back to visit
with Jo, the 5 & 8/12 year-old female child. She is here for complaints of
behavioral difficulties and poor performance in school. Mother reports since
moving back in with her parents that Jo has started throwing tantrums and
refusing to obey. The mother reports that she has always been active with
frequent changes in activity and difficulty in staying seated or minding her
own business. However, since the move and starting kindergarten, others have
commented on difficulties in behavior, including Kayla’s own parents and Jo’s
teacher. She is doing poorly in school and has had many behavioral issues there
and been sent to the principal’s office on three occasions. She has not yet
been to see the opthamologist as you suggested.

PMH: No change in diet; no fever;
no communicable disease symptoms; continues children’s chewable multivitamin
with iron daily; sleep includes going to bed around 10:30 p.m. at night and
being awakened at 6 a.m. for school. She continues to be difficult to get in
bed with frequently getting up in the first hour of bedtime.

Discussion Questions Part One

What additional OLDCART and ROS
information would you like? Why?

Differential diagnoses with
rationale?

Further history and ROS needed to
more fully develop your differential diagnoses?

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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