In your responses to two post, you must include the following: Your top three (3) differentials based on the information provided and why (rationale based on presentation findings), the primary diagnosis you are leaning toward, how you would treat that diagnosis. Use references to support your response.
S.G., 16 years old Caucasian female, BCBS insurance
CC: muscle spasms and nightly vomiting
HPI: S.G. is a 16 years old female who presents accompanied by her mother to a sick visit. Patient has been diagnosed as a child with Angelman’s Syndrome, is non-verbal, and unable to recall the symptoms, and all information is obtained from the mother. The patient has developed muscle spasms that last 30 seconds, and occur every 1-2 hours during the day. The muscle spasms are a new finding, that developed 2 months ago. The muscle spasms do not happen in relation to an activity, and they happen most often at rest. The patient has been see by the neurologist that follows her closely, without a resolution, or treatment plan. Around the same time when she developed the muscle spasms, 2 months ago, she also developed nightly vomiting one hour after laying down in bed. Her vomiting is projectile, and consists of digested food, and normal consistency and color. The mother denies any blood in the emesis. The vomiting episodes last a few minutes, and they occur every 2 hours throughout the night. The patient does not vomit during the day. She is taking every evening ranitidine tablets, with no resolution in her symptoms. The vomiting does not appear to be aggravated by certain foods.
Ranitidine 300 mg capsules, 1 capsule QHS for GERD
Levetiracetam 500 mg tablets, 1 tablet BID for partial seizures
Allergies: hay fever, dander
Immunizations: Up-to-date, refuses influenza vaccine
PMHX: Otitis media at 3 years old, seizure disorder diagnosed at 2 years old, Angelman’s syndrome diagnosed at 4 years old.
PSHx: Appendectomy at 13 years old
Social Hx: Lives with mom and dad, who provide 100% of her care. Patient is dependent on care with feeding, toileting, and dressing. Patient is home schooled. No siblings, or pets in the house.
Fam Hx: Father: alive and well; Mother: Diabetes Mellitus, and Hyertension, alive; Paternal grandmother: HTN, and alice; Paternal grandfather: colon cancer, deceased. Maternal grandmother: HTN, hyperlipidemia, alive; Maternal grandfather: HTN, and alive
CONSTITUTIONAL: Mother reports newly onset muscle cramping, and vomiting and feeling more lethargic than usual. She has a decreased appetite, tolerated liquids and foods as usual. She has no recent weight loss, but she wakes up every night to vomit.
SKIN: None reported
HEENT: Mother denies poor vision, complains of ear pain, nasal drainage or congestion
RESPIRATORY: Mother denies a cough
GI: Mother reports a decreased appetite. Has nighly vomiting for the past 2 months
GU: Mother reports adequate urinary output
Vital Signs: BP: 112/63; T: 98.3 (oral), HR: 82, RR 16, SpO2: 100% on RA
Length: 150 cm ; weight : 60 kg
Development: Growth Chart: 75th percentile for weight to age, 10th percentile for height to age, BMI :26.7 ; Tanner Stage 5
General: Patient is alert and quiet, with a lethargic appearance. She is well-nourished, dressed and groomed appropriately. No visible acute distress.
HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact, sclera non-injected. External auditory canal normal, bilateral TMs intact. Bilateral nares patent, nasal mucosa erythematous and moist, bilateral turbinates pink and moist. Posterior pharynx pink and moist, and tonsils 2+. Neck normal to inspection, trachea midline, non-palpable lymph nodes.
CV: Regular rate and rhythm, S1, and S2 heard, no extra sounds, murmurs or gallops heard
RESP: Respirations are regular and non-labored, normal respiratory rate, lungs clear to auscultation bilaterally
Abdomen: Soft, non-tender, normal active bowel sounds, non-tender on light and deep palpation
NEURO: alert and oriented, intact EOMs, alert, unable to assess orientation due to patient being nonverbal and non-responding to commends
MSK: good motor tone, 5/5 strength with pedal push/pulls, and arms push, pull.
Diagnostic tests: none available
J.A, 14 years, Male, Hispanic
CC: Increased hunger and thirst
J.A reports increased hunger and thirst for the last 3 months. He has been feeling weak and tired most of the time. Playing football or tennis worsens the symptoms. The patient has not tried any medications or therapy to relieve the symptoms.
Immunizations are up-to-date, no past major illness or surgery, no known allergies
9th-grade student, negative for alcohol and tobacco use, sexually inactive, plays football and tennis
Mother and father alive, mother has hypertension, father has type 1 diabetes, siblings are healthy
General: Patient is normal and alert, positive for recent weight loss, negative for fever and night sweats
HEENT: Positive for episodic blurry vision and headaches, does not wear glasses, hearing is okay, negative for nasal congestion
Endocrine: Positive for increased urination, negative for thyroid problems, excessive sweating and heat or cold intolerance
Hematological: Negative for anemia
Neurological: Positive for dizziness, negative for blackouts, seizures and numbness
Lymphatic: Negative for swollen lymph nodes
Gastrointestinal: Negative for anorexia, vomiting and diarrhea
Blood Pressure, 103/70 mmHg
Heart rate of 62 BPM
Respiratory rate, 13 breaths per minute
Body temperature, 100.1 Fahrenheit
Underweight, dry skin, PERRLA eyes, normal sensation in extremities, no blisters, cuts or sores in the extremities
A1C level of 6.7 percent, fasting blood sugar of 128 mg/dL, glucose urine test (1+)
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