tooth pain

 Please evaluate the subjective and objective information provided to you in the file below.
The first part of the discussion board is to identify all pertinent positive and 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
CASE STUDY:
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

Leave a Reply