Today you note that Kayla is back with Jo for behavioral issues

PBL Case Discussion: Issues in Growth and Behavior Part One (graded)

Today you note that Kayla is back with Jo for behavioral issues.

HPI: Kayla (mom) is back to visit with Jo, the 5 & 8/12 year-old female child. She is here for complaints of behavioral difficulties and poor performance in school. Mother reports since moving back in with her parents that Jo has started throwing tantrums and refusing to obey. The mother reports that she has always been active with frequent changes in activity and difficulty in staying seated or minding her own business. However, since the move and starting kindergarten, others have commented on difficulties in behavior, including Kayla’s own parents and Jo’s teacher. She is doing poorly in school and has had many behavioral issues there and been sent to the principal’s office on three occasions. She has not yet been to see the opthamologist as you suggested.

PMH: No change in diet; no fever; no communicable disease symptoms; continues children’s chewable multivitamin with iron daily; sleep includes going to bed around 10:30 p.m. at night and being awakened at 6 a.m. for school. She continues to be difficult to get in bed with frequently getting up in the first hour of bedtime.

Discussion Questions Part One

What additional OLDCART and ROS information would you like? Why?

Differential diagnoses with rationale?

Further history and ROS needed to more fully develop your differential diagnoses?

Discussion Part Two (graded)

Physical Examination: Jo

Age: 5- 8/12 year-old female

Vital Signs: Height: 115 cm, Weight: 31 kg B/P:102/68, T: 97.9, HR: 90 BMP/reg., Resp: 18, reg, non-labored, SpO2: 99% Weight percentile: 99.1%, Height percentile: 64.0%

HEENT: Head normocephalic atraumatic, hair thick and distributed throughout entire scalp; conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; pinna/tragus w/o tenderness; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; primary tooth eruption to include first molars upper and lower; no loose teeth; oral exam unremarkable; neck supple w/o lymphadenopathy; thyroid small, firm, equal bil. Vision remains unchanged from her first visit.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen sl. rounded normoactive bowel sounds throughout, soft, non-tender, no masses, or organomegaly; peripheral pulses reg., equal., intact bil radial and pedal.

Musculoskeletal: MAE

Cognitive or Behavioral: The patient was uncooperative this visit. The patient hides behind the exam table and tells her mother “no” frequently. She takes the exam paper off of the table, crawls around behind the exam table and kicks at her mother when the mother attempts to pull her out. You are able to get her out from under the table with much coaxing and a promise of a popsicle. There is difficulty to get her to stay focused while you examine her, and she asks frequent, tangential questions. She can copy a circle, square, and write her name but she has not yet learned to read or write letters beyond this.

Discussion Questions Part Two

Please add the following to your response:

Primary diagnoses and differential diagnosis with rational and the following in brief for your primary diagnosis:

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