Reference no: EM133883788

Question

You are seeing a 9-year-old African American girl (Serenity) today for a well visit. Serenity Details on Serenity's chart: Birth History: 39 weeks gestation-repeat c-section, no complications per Paternal Grandmother (PGM) who is with her today. Medications: None, Allergies: NKDA, PMH/PSH: See birth HX, UTD on immunizations, Social History: Attends 4th grade, lives with Dad and PGM (mom deceased), no smoking in the home, pet hamster, Family History: PGF and Dad with blood in their urine since childhood, Dad in his mid-thirties alive and well, no siblings. CC: 9 year Well Visit, HPI: Serenity presents for her yearly Well visit. Potty trained at 2 years old, Eating well balanced diet with fruits and vegetables, drinking well (water and milk). PGM mentions that every year they find "blood in her urine". Vitals: 100/64, 98.8, 80, 20 Ht: 95th% Wt: 75th% BMI: 20 PE: HEENT: Head: normocephalic, Eyes: conjunctiva pink, no discharge noted, no peri-orbital edema noted, Ears: TM pearly grey bilaterally, no fluid noted, Throat: tonsils 1+, pharynx pink, no drainage or exudate noted, CV: S1 S2, no rubs, clicks or murmurs, Lungs: CTA bilaterally in all fields, Abdomen: soft, non-tender, no ascites noted, GU: no adhesions or edema noted, tanner stage

1. Ask them five questions to get additional information to treat your patient. Include a rationale for why you want to know this information. Explain your rationale as though the patient asks why you asked them that question. For example, you might say, "Has your child hit his head? I am asking because a head injury may indicate a concussion."

2. Discuss your primary diagnosis for the problem, along with 3 possible differential diagnoses (give EBP rationale for your choices).

3. Finally, as if you are speaking to the care giver provide Education related to diagnosis, labs and/or diagnostics recommended, treatment/management, prevention, and Age-Appropriate Anticipatory Guidance for your patient.