Adolescent Cardiovascular Disorder Case Study

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Adolescent Cardiovascular Disorder Case Study

Instructions: This case study consists of a hypothetical patient situation. After reading the case study document, you are to complete the case study related to this patient. You will use outside materials to support your assignment. Peer reviewed articles. Please Do Not Use Up To Date. Please use peer-review appropriate source to cite case study.

ASSESSMENT
1. Please provide Three Differential Diagnoses with cited rationale, ICD-10 codes and description associated with codes.

2. Please provide Two Medical Diagnosis with cited rationale, with ICD-10 codes and description associated with codes.

3. PLAN • Prescriptions: dosage, route, direction / instruction. • Non-Pharmacological- Referrals required (if applicable) • Return to clinic (RTC) in what time frame and reason for next visit/Interventions

About the Patient: Henry

Chief Complaint:
• Preparticipation physical examination (PPE).
• Doing well except for occasional chest pain upon exertion for the past three months.

Henry is a 15-year-old male who presents in your primary care clinic with his father for a pre-participation physical examination (PPE). His father states that Henry is a star on his football team and needs to have his PPE completed to play in Friday night’s game. Henry states he has been doing well except for occasional chest pain upon exertion for the last three months. Henry states that the pain feels like a tightness and goes away after he rests for ten minutes. Henry has checked his blood pressure (since his dad has high blood pressure) and the readings for the past three months have ranged from 130 to 140 over 88 to 94.
Henry’s past medical history reveals no hospitalizations, surgeries, or allergies. Henry does not take any medication and denies use of any dietary supplements. Henry had routine labs completed at his last well child check about 6 months ago which included a CBC, CMP, urinalysis, and fasting lipid panel. All results were within normal limits. Henry has not had any radiographs done.

Henry’s social history is unchanged. Henry lives at home with his father and 12-year-old brother. They have no pets. Father smokes outside of the home. Henry denies tobacco use, alcohol use, vaping, or any illicit drug use.

Henry is in the 11th grade and has a B average. He has several friends his age. Henry denies any unprotected sexual activity, stating he wears a condom each time. Henry is on the varsity football and wrestling teams. There is no concern of food availability.

Henry’s family history includes his mother as deceased, auto accident at 32 years of age. Father with a history of hypertension on medications, paternal grandfather with hypertension, diabetes; maternal grandmother with thyroid disorder, maternal grandparents alive and well with no history of hypertension, hypercholesterolemia, thyroid disorders, heart disease, or diabetes.

Henry’s immunizations are up to date including the seasonal influenza vaccine.
Henry has met all expected milestones at 15-year-old well-child check.
His vital signs at present: Weight: 225 lbs. (99th percentile) Height: 74 in. (99h percentile); Temp: 97.2 F, P: 76 RR: 16 BP: 140/94 (99th percentile)

Physical Exam:

Cardiovascular: Grade II/VI systolic murmur heard best between the apex and the LLSB. The murmur is quieter with squatting and louder with Valsalva maneuver. There has been no history of a murmur in the past. His last BP at his well-child check was 120/76. He has not had any cardiac testing done in the past and he has not been seen by a cardiologist.
All other aspects of the exam are normal. Please write up the physical exam for this child, addressing pertinent systems in both the Review of Systems (Subjective) and the Physical Exam (Objective). As you write up the note, consider if the child is normotensive, prehypertensive, Stage I or Stage II hypertensive.
In your presentation, consider if you as the primary care provider can clear the child to play Friday night’s football game

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