ELIUD PETERSON

Name: O. R

Date: 04/11/2018

Sex: M

Age/DOB/Place of Birth: 17-year-old/ October 20, 2000, Miami, Fl

SUBJECTIVE

Historian: Patient is a 17-year-old Caucasian male with no developmental delays. Patient is able to provide information about his present concern.

Present Concerns/CC: “During the last 2 week I have been suffering with a terrible headache. I also have been feeling nauseas and vomiting. I thought it was related to my stress levels due to finals at the school but a week after still have the symptoms”

Child Profile: As per member, he is an honor student in classes. He is in 11 grades. He loves to play basketball with his older brother who is in college and 2 other friends who play together in the basketball team at the school. His dream is to become a professional basketball player. He wears a seatbelt in the car. He lives with his biological parents and his older brother in a house. Member assist his mother with some house duties such mopping, cleaning, taking care of the trash. He walks his dog daily and assist with his feeding. He plays video games when he is at home.

HPI:

A 17-year-old male with no known health history presents to the clinic with his mother, complaining of headaches and nausea with vomiting for the last 2 weeks. Intermitted headache pain throughout the day time reported. He describes his pain as sharp to the left and posterior area of his head. Pain level of 3 in the scale of 10 at this time but sometimes at night the pain can be moderated, 5 of 10. Patient states that he takes some Tylenol for his headache and Perrier water to calm his stomach for the nausea and vomiting.

End of Visit HPI:

Patient presents with headaches and nausea with vomiting for the last 2 weeks. Preceptor did orthostatic vital signs (negative).

Medications: None

PMH:

Allergies: NKDA

Medication Intolerance: None

Illnesses/ Major Traumas: None

Hospitalizations: None

Immunizations: Up to date

Family History

Maternal Grandmother: Alive - Osteoarthritis

Maternal Grandfather: Alive - Obesity and Diabetes mellitus

Paternal Grandmother: Alive - Hypertension

Paternal Grandfather: Alive - BPH

Father – Healthy

Mother – Migraine at age 15

Brother – 1, Healthy

Social History

As per member, he is an honor student in classes. He is in 11 grades. He loves to participate in

after school activities. He loves to play basketball with his older brother who is in college and 2

other friends who play together in the basketball team at the school. His dream is to become a

professional basketball player. He also likes to play video games with his friends. As per member,

he has a girlfriend for about 2 weeks, they are not having sex.

ROS

General

Reports severe, sharp pain to the left and posterior area of his head. Pain level of 3 in the scale of 10 at this time but sometimes at night the pain can be moderated, 6 of 10 that wake him up at night and nausea with vomiting x 2 weeks

Cardiovascular

Denies chest pain, palpitations, or tightness

Skin

Denies rash, bruising, skin discoloration, or lesions.

Respiratory

Denies shortness of breath, dyspnea, snoring or history of pneumonia.

Eyes

Denies any difficulty with vision, pain, or discomfort.

Gastrointestinal

Denies constipation, denies eating disorders. Admits to nausea with vomiting x 2 weeks ago. Denies change in diet. Reports last vomited this morning after breakfast. Reports appetite has decreased during the last week

Ears

Denies pain, hearing loss or ringing in the ears.

Genitourinary/Gynecological

Denies urgency, burning sensation, penile discharge, frequency, dysuria, hematuria, or change in the color of urine.

Nose/Mouth/Throat

Denies mouth sores, sore throat, pain, nasal drainage, or nosebleed.

Musculoskeletal

Denies any complications with range of motion in all four extremities, stiffness, fractures, or musculoskeletal abnormalities. He denies injuries or trauma to his head

Breast

Denies any lumps, pain, or lesions. Tanner Stage II, breast buds

Neurological

Denies seizures. Admits severe headaches

Heme/Lymph/Endo

Denies any bruising or bleeding

Psychiatric

Denies sleeping difficulties, suicidal ideas, or attempt.

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight: 82 kg

Temp: 97.3 F

BP: 117/61 mmHg

Height: 77 inches

BMI: BMI = 22.50 kg/m2 90th Percentile

Pulse: 71 x’

RR: 20 x’

SpO2: 99% at room air.

General Appearance and parent‐child interaction

High school male is appropriate and respectful. Interacts well with office staff. He can answer the questions without any difficulty. He has good eye contact during the assessment and verbalized his concerns.

Skin

General skin is warm, dry, and intact. No lesions, lumps, bruising, or other discolorations noted.

HEENT

Head: hair evenly distributed. Eyes: pupils equal round reactive to light, positive Red Reflex, bilaterally and accommodation. Eye sight is 20/20 in right eye and 20/20 in left eye. No crust builds up or drainage. Ears: Both ear canals are patent. Tympanic membrane is opaque in color. No indications of rupture or pus. Nose: nasal mucosa pink and moist with normal turbinate’s. No deviation to septum. Neck supple, full range of motion. No cervical lymphadenopathy. Oral mucosa moist and pink. Pharynx erythematous and with no exudates. Teeth are in good condition.

Cardiovascular

S1, S2 regular rate and rhythm without murmur. Bounding pulses 3+ throughout all extremities. No edema. Capillary refill less than 2 seconds. Skin is warm to touch.

Respiratory

Chest wall symmetric with even chest rise during respirations. Regular, even, and unlabored breathing.

Gastrointestinal

Abdomen soft non-tender, bowel sounds are active in all four quadrants. No hepatosplenomegaly. Last bowel movement was this morning after breakfast.

Breast

Tanner Stage IV. Adult hair present in chest. Coarse hair noted in axillary areas.

Genitourinary

Bladder is not distended. Tanner Stage IV. Hair is full, limited in area. Urine is clear.

Musculoskeletal

Full range of motion in all four extremities. Observed patient move about in the exam room. Gait is intact. No popping or cracking sounds with movement.

Neurological

AAOX3, answers questions appropriately and can communicate well. Speech is clear. Posture is erect and balance is stable. Gait is normal. Good eye contact with conversation. Comprehensible and well-developed thoughts. Cranial nerves 2-12 intact.

Psychiatric

Denies depression, sleeping difficulties, suicidal ideation or attempts, or previous mental health problem.

In-house Lab Tests – None

Pediatric/Adolescent Assessment Tools

Patient lives with biological parents and older brother. He has one dogs at home. He oversees his dog feeding and daily walks. He is in high school, eleven grades. He enjoys playing basketball with his older brother and his friends. He also plays some video games during his free time. Patient is aware of dialing 9-1-1 in case of emergencies and has his immediate family member’s numbers stored in his phone. He understands what to do during a fire and knows all the exits in the house. He understands the peer pressure problems and denies being pressured to using any illicit drugs or alcohol. He understands to obey authority and comply with law enforcement. He is not sexually active with his girlfriend, but he is aware to wear condoms.

Diagnosis

· 1. Cluster headache ICD-10 G44.009: series of relatively short but extremely painful headaches every day for weeks or months at a time. The pain is almost always one-sided, and it stays on the same side during a period, the time when you're getting daily attacks (Cluster Headaches, 2006).

· 2. Tension headaches ICD-10 G44.209: occur when neck and scalp muscles become tense, or contract. The muscle contractions can be a response to stress, depression, head injury, or anxiety. Usually severe in nature; unilateral; orbital, supra-orbital, and/or temporal; and lasts 15 to 180 minutes (Tension headache, 2018).

· 3. Posttraumatic headache ICD-G44.309: headaches following a well-defined concussive head injury are not unusual and are likely to remit over a period of a few days or some weeks. Symptoms of post-traumatic headaches; head pain, dizziness and nausea and vomiting, double vision and memory problems (Post traumatic headaches, 2018).

· Primary diagnosis

Migraine G43.909 is defined as recurrent headache that occurs with or without aura and lasts 2 to 48 hours. It is usually unilateral in nature, of gradual onset (15 to 30 minutes), pulsating in quality, of moderate or severe intensity, and is aggravated by routine physical activity. Nausea, vomiting, photophobia, and phonophobia are common accompanying symptoms (Migraine, 2017).

· Plan:

Pharmacological: Ibuprofen 200mg orally every 4 to 6 hours as needed for pain, max: 2400 mg/day.

Nonpharmacological: Reduce stress. Because stress triggers migraines for many people, try to avoid overly stressful situations, or use stress-reduction techniques such as meditation. Get enough sleep. Aim for a regular sleep schedule and get an adequate amount of sleep. Keep a headache diary, this will help him to spot the migraine triggers. Note when your headaches start, how long they last and anything that provides relief. Record response to any medications. Also note the foods you ate in the 24 hours preceding attacks, any unusual stress, and how you feel and what you're doing when headaches strike.

No laboratory test or diagnostic test ordered. Follow up in 1 week to review diary and effectiveness of treatment.