What else would you want to ask about the history

Reference no: EM133562933

Case 1

A 9 year old male was rushed to ER due to elevated BP

He was thriving well with no complaints until when he was 5 years old, he started to complain of frequent headaches which he claims to be tolerable and relieved with intake of paracetamol. He also often complains that his legs hurt whenever he walks going to school. He was brought to an optometric shop where he was given prescription glasses. No other consultations were done. The headache did not resolve with the glasses however no further consultation was done. The parents also did not entertain the leg pain complain since they think the patient just doesn't want to go to school

Few hours prior to consult, during their PE at school, the patient again complained of headache. He was brought to the school clinic. BP was taken and was noted to be 180/100. He was then immediately rushed to ER.

At the ER

The patient was awake, in pain

BP upper extremity 170/120, BP lower extremity 90/60, HR 115, RR 23, temp 37.1 sats 96%

Anicteric sclerae, pink conjunctivae, no Tonsillopharyngeal congestion

Symmetric chest expansion, good air entry, clear breath sounds

Adynamic precordium, (+) thrill at the suprasternal notch, tachycardic, regular rhythm, Gr2 SEM in upper left sternal border radiating to the L interscapular area posteriorly

Soft, flat abdomen, normoactive, no organomegaly

Bounding radial and brachial pulses, thready femoral and popliteal pulses

Give 5 pertinent data from the history and PE
What else would you want to ask about the history of the patient? Give 5
What is your diagnosis?
What is the pathophysiology of the lesion?

Case 2

A 5 year old male was brought to your clinic due to poor weight gain.

The patient was born full term with unremarkable prenatal and birth history. There were no complains except that the child has poor weight gain ever since he was a baby. The parents attributed this to the poor eating habits of the child. He was being dewormed 2x a year with occasional passage of worm. He was brought to your clinic because the parents would like to ask for prescription of vitamins and milk to help the child gain weight.

PE:

Awake, comfortable, Wt 12kg

VS: BP 90/60, HR 90, RR 20, temp 36.8, sats 97%

Anicteric sclerae, pink conjunctivae, no Tonsillopharyngeal congestion

Symmetric chest expansion, good air entry, clear breath sounds

Adynamic precordium, normal rate and rhythm, S1 normal, S2 wide and fixed split, (+) 2/6 systolic ejection murmur at the left upper sternal border

Soft Abdomen, no organomegaly

Warm extremities, Full pulses

Give 5 pertinent data from the history and PE
What else would you want to ask about the history of the patient? Give 5
What is your diagnosis?
What is the pathophysiology of the lesion?

Reference no: EM133562933

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