MSN 610 CS3 CASE STUDY 2021/22 100% LATEST

J. B is a 17 year old male who present with his father (who is main historian) to your clinic for recurrent vomiting and abdominal pain. His father states that he has missed a lot of school and to prevent truancy allegations, he is required to present a physician’s excuse to justify the frequent absences. When you ask him how often this occurs, J.B. tells you that he experiences nausea and vomiting that comes and goes, and has abdominal pain “most all the time”. He wakes with abdominal pain and nausea and is afraid to go to school for fear of vomiting. He also admits to weight loss since the beginning of the school year. When asked if he has tried anything to relieve the nausea and vomiting, he tells you that sometimes he feels better after a long hot shower. PMH: Recurrent URI’s as a child. Immunizations are UTD. Surgical History: PET’s at age 2 for recurrent otitis media, tonsillectomy at age 8. Medications: Zoloft 25mg once daily SH: Parents are divorced. J.B. sees his mother “rarely”. J.B. and his father live in a single family home in a middle class neighborhood. He denies involvement in sports at school, but occasionally plays basketball in the driveway. He “hangs out” with friends on weekends. He smokes 3-4 cigs per day for “a year or more” and openly admits to using marijuana at home after school; he denies alcohol consumption. He failed 9th grade and is currently a Junior at his local HS. FH: Mother is living, age 42. No known health problems. Dad, age 45, smoke 1 ppd x 15 years, hypertension, migraine headaches. No siblings. ROS: Tall, very thin young man with shoulder length hair, well kept, clean. Weight loss of 5 kg since the beginning of the school year (6 months). Head: Denies trauma, admits to frequent headaches, denies hair loss EENT: Denies vision changes, watery eyes, hearing loss, nasal congestion or bleeding, facial pain, admits to sore throat with emesis Neck: Denies dysphagia, swollen glands or neck stiffness Respiratory: Admits to occasional cough, denies SOB, wheezing Cardiac: Denies chest pain, palpitations, swelling Gastrointestinal: Admits to decreased appetite, denies bilious emesis, diarrhea or constipation, Admits to periumbilical abdominal pain and states normal bowel habits. Genitourinary: Denies urinary frequency, pain or incontinence. Denies testicular pain or penile discharge. Musculoskeletal: Denies joint pain, weakness, numbness or tingling Hematologic: denies excessive bruising or bleeding Neurologic: Denies seizures, tics, syncope, admits to occasional dizziness especially with vomiting Nutrition: Does not eat breakfast most days. Eats school lunches, and usually frozen pizza or frozen pizza rolls at home. Drinks water or soda. Eats vegetables “sometimes”. Physical Exam: WT: 125 lbs HT: 6’3” T: 38.6C BP: 120/72 HR: 109 Resp: 22 O2 sat : 98% General: Tall, thin, appropriately groomed and appears his stated age. Affect generally flat. Frequently looks at his father for affirmation. This study source was downloaded by from CourseH on :01:10 GMT -06:00 Skin: Moist, without rashes or lesions, no tenting noted HEENT: Normocephalic with evenly distributed hair. PERLA, optic disk with clear margins, conjunctiva clear and pale, R-TM visible grey with visible cone of light; L canal with cerumen impaction, unable to visualize TM. Nares patent and clear, no polyps noted. OP appears moist, dental caries suspected on left lower molars, buccal tissue pink, no malodor noted, uvula midline, FROM of tongue, pharynx unremarkable. Neck: FROM, no lymphadenopathy, thyromegaly, JVD Heart: Regular S1S2, no murmurs, gallop or rubs, PMI @5ICS MCL Lungs: CTA bilaterally with equal excursion and normal tactile fremitus Abdomen: Soft, NTND, no HJR, no masses. Liver edge palpable, no HSM. Hypoactive BS x4. No palpable inguinal nodes. Peripheral vascular: No edema with +2 palpable radial, popliteal, pedal pulses bilaterally noted. Musculoskeletal: FROM all extremities, no joint swelling or pain in upper or lower extremities. Neurological: CN 2-12 grossly intact Psychological: Alert, quiet. Poor eye contact during evaluation and exam. Limited communication with provider. List the “red flags” in this case.  Vomiting  periumbilical abdominal pain  absence from school  nausea  weight loss 11-pound weight loss in 6 months (BMI 15.6)  Taking Zoloft 25mg daily  divorced parents  Rarely sees mother  Tobacco use  Marijuana use  Failed 9th grade  Frequent headaches  Sore throat with emesis  Occasional cough  Decreased appetite  Dizziness with vomiting  Flat affect  Looking at father for affirmation  Cerumen pack left ear canal  Dental caries  Hypoactive BS x4  Quiet  Poor communication  Father answers most questions  Tachycardia  Poor eye contact