Oral Examinations on Clinical Analysis

Instructions
It is anticipated that the initial discussion post should be in the range of 250-300 words. Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.
Instructions:
• Please evaluate the subjective and objective information provided to you in the file below.
C.C. tooth pain

HPI: M.M. is a 5 y.o. F who present to HU clinic with her mother. Recently, M.M had presented for her 5 y.o. Well-child visit. A week later returned due to night terrors. Today presented to clinic for tooth pain, one week after the night terrors. Mother reports night terrors are still occurring at least once a week. M.M. is still not aware of the night terrors. Mother is concerned because yesterday M.M. would not eat reporting that her teeth hurt and was sleeping more after school. Today, she has some swelling to left lower jaw and mother reported a fever. No temperature was obtained but she had felt warm. Mother gave her a dose of Tylenol and her mood improved. Mother reports not having seen a dentist yet. They try to brush her teeth twice a day but sometimes allow her to brush them. 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: Review of Systems General: Concerned about not eating, and sleep morning. Skin: Denies any rash, lesions, or concerns with eczema. Head: Denies headache, trauma or falls. Swelling noted to lower jaw. ENT: Denies any concerns ears, nose, or throat. Reporting tooth pain when eating. 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. Objective VS: Temperature: 100 F, 97/71, HR: 100, RR: 20, 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. Head: Normocephalic. 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. Swelling, erythema noted to gingivae to left lower tooth line and right upper posterior gumline Oropharynx: normal mucosa, palate, and posterior pharynx. Neck: Supple, Small non-mobile adenopathy on L posterior cervical chain. 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. GU: Normal female genitalia. Tanner stage 1. MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.

• The first part of the discussion board is to identify all pertinent positive and pertinent 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, as well as expected health promotion and expected developmental milestones.
• Be sure to include APA in-text citations and provide full reference citation at the end of the discussion