The patient is a 12-year-old female presenting with severe head and neck pain following a fall during cheerleading practice yesterday. While performing as a flyer at the top of a pyramid, she was unable to counterbalance quickly enough, and her spotter missed her. She fell hard onto the mat, primarily landing on her right side, and witnesses reported that she briefly “bounced up” upon impact. She did not lose consciousness and initially had no head pain, though she felt<\/p>\n
“jarred.”<\/p>\n
After the fall, she rested briefly, went home, had a light snack, skipped dinner, and slept through the night. This morning, she woke up with a constant, severe, throbbing headache, primarily in the right frontal area and radiating across her head, rated at 7-8\/10, described as a deeper, internal pain. She also reports light sensitivity, noticing the brightness outside this morning. She has not taken any medication for the headache.<\/p>\n
In addition to the head pain, she describes her neck as tense and sore, particularly when moving her head down or to the left, with a pain rating of 1-2\/10, describing it as more stiffness than actual pain. She also reports nausea that started this morning and was unable to eat breakfast, though her mother made her drink water. She has not experienced vomiting.<\/p>\n
The patient feels mentally “foggy,” with difficulty making decisions, such as choosing what to wear, and reports trouble concentrating. The patient’s mother, who has a history of migraines beginning at age 12, noticed her daughter appeared foggy this morning and brought her in for evaluation before school. The patient is alert but seems uncomfortable, exhibiting good hygiene with warm, dry skin. Her eyes are closed, and she rests her head in her hands. She denies any significant changes in weight or unusual growth patterns. She is sitting upright on the exam table, holding her head. <\/span>he patient denies blurred or altered vision but reports sensitivity to light, specifically noticing increased brightness outside this morning. She denies any sensitivity to sounds, rhinorrhea, ear pain, sore throat, or eye discharge.Headache: The patient describes her headache intensity as 7-8\/10.Neck: She reports mild neck pain rated at 1-2\/10, which increases when she tilts her head downward and to the left. <\/span>The patient denies any murmur, syncope, excessive fatigue, dyspnea, chest pain, palpitations, or cyanosis. <\/span>The patient denies shortness of breath, wheezing, difficulty breathing, or any respiratory distress. <\/span>Reports nausea but denies vomiting, diarrhea, or constipation. <\/span>The patient is up to date on annual well visits and there are no smokers or firearms in the home. The immunization history is as follows: at birth, the patient received the Hepatitis B vaccine. At 2 months, they received DTaP, IPV, HIB, PCV13, Rotavirus, and another Hepatitis B dose. At 4 months, the patient received DTaP, IPV, HIB, PCV13, and Rotavirus again. At 6 months, the vaccines included DTaP, IPV, HIB, PCV13, Hepatitis B, and Influenza. At 9 months, the patient received the Influenza vaccine. At 12 months, they received MMR, Varicella, and Hepatitis A. At 15 months, the patient received DTaP, HIB, PCV13, and IPV. At 18 months, another Hepatitis A vaccine was given. At 24 months, they received the Influenza vaccine, which continued at 36 months, 48 months, and 60 months, alongside MMR, Varicella, IPV, and Tdap at 60 months. Influenza vaccines were administered again at ages 6 through 10 years. Finally, at age 11, the patient received HPV, Meningococcal, Tdap, and Influenza vaccines. social histioy.: <\/span><\/p>\n <\/span>Natural parents, with no siblings. Parents are married and employed, living in a single-family home. The family recently adopted a new cat.<\/p>\n Screening Questions:<\/p>\n Alcohol: Denies use<\/p>\n Drug Use: Denies use<\/p>\n Seatbelt: Yes<\/p>\n Bike Helmet: Yes<\/p>\n Food Insecurity: No<\/p>\n Firearms in Home: No Family history: <\/span>Natural Mother: Migraine headaches<\/p>\n Natural Father: Irritable bowel syndrome, anxiety<\/p>\n Siblings: None<\/p>\n Maternal Grandmother: Migraine, stroke at age 70<\/p>\n Maternal Grandfather: Myocardial infarction at age 65<\/p>\n Paternal Grandmother: Migraine headaches<\/p>\n Paternal Grandfather: Lung cancer<\/p>\n Great Grandparents: Negative; medical history unknown<\/p>\n Aunts and Uncles: Maternal aunt with depression. <\/span><\/p>\n <\/span><\/p>\n <\/span>Need Management Plan(CLINICAL GUIDELINES)<\/p>\n <\/p>\n Primary diagnosis: with ICD-10 Code and <\/span>Guidelines used to develop this primary Test\/Results: (CPT Code<\/span> <\/span>(CPT Code )<\/span><\/p>\n \u2022 Office Visit Code: <\/span><\/p>\n <\/span>Differential Diagnoses 3-4 ICD-10 : <\/span><\/p>\n <\/span>Medication: <\/span><\/p>\n Patient Education: <\/span><\/p>\n Health promotion: <\/span><\/p>\n Social Determinants of Heath (SDOH): <\/span><\/p>\n <\/span>Follow up: <\/span>timing\/when. CPT Code -: <\/p>\n “red flags”5 numbers. <\/p>\n Referrals: <\/span><\/p>\n References:<\/p>\n","protected":false},"excerpt":{"rendered":" The patient is a 12-year-old female presenting with severe head and neck pain following a fall during cheerleading practice yesterday. While performing as a flyer at the top of a pyramid, she was unable to counterbalance quickly enough, and her spotter missed her. She fell hard onto the mat, primarily landing on her right side, […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[13],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/36406"}],"collection":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/comments?post=36406"}],"version-history":[{"count":0,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/36406\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/media?parent=36406"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/disciplines?post=36406"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/paper_types?post=36406"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/tagged?post=36406"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}