Posted: March 30th, 2022
Diagnosis of Patient
The author of this report has been asked to diagnose a youth that has come in complaining of an inability to sleep. The girl seems to be in good overall health but she is having some pain. She does not pay a whole lot of attention to the doctor as the doctor enters the room. She briefly glances up and says hello but looks back down. The child apparently has a fixation on computer and phone use and the mother believes this is a factor. The child retorts that the use of the phone and the computer is instead a distraction from the pain she is experiencing. There are no previous childhood illnesses and the she has not been diagnosed with any chronic illnesses. There have been no hospitalizations or surgeries. Immunizations are completely up-to-date at this point. There have been no blood transfusions. The child denies use of alcohol, tobacco or any illicit drugs. The girl has no current medications and had her last period about a week ago. She is a good student and lives with her parents and siblings. As for family history, the biological mother has no issues to speak of but the father has bipolar disorder, albeit controlled. The siblings of the patients are in good health. Both of her grandmothers (paternal and maternal) died from breast cancer. The maternal grandfather died of lung cancer. The paternal grandfather is alive but has type II diabetes.
The author of this report would ask the patient a few questions. Firstly, there would be the question of where the pain is located, how strong it is (on a 1-10 scale) and how often it happens including how long it occurs each time it happens. The doctor should ask if there are common activities or behaviors that are going on when the behavior occurs (like using the phone or computer). The notes thus far indicate it is limited to headaches and this is causing her to not be able to sleep. There are a couple of diagnoses that could be in play here but the list is not very long.
Unless the patient reveals anything new, the most likely cause of her issues is indeed what her mother thinks it is and that is excessive staring at her computer or phone. This is likely causing eye strain as well as her headaches. The headaches are likely what is causing her to not be able to sleep. As explained by many sources, excessive time in front of computers or smartphones can cause head, back, neck and shoulder pain due to posture problems and strained eyes (Newcomer, 2012). Based on the girl’s ostensible fixation with her phone, that is almost certainly the issue. The Type II diabetes in her remaining grandparent is something to look at but there are no symptoms being reported that are consistent with high or low blood sugar and there is nothing said about the girl being overweight. Further, her parents and siblings do not have it. The girl could also have migraines that are not related to computer use but are happening nonetheless. Bipolar would seem to be unlikely given that she is not really expressing any symptoms of it. Thus far, we have computer over-use leading to headaches and general migraines as the two differential diagnoses with the former being more likely than the latter (May, 2016).
The third and final possible diagnosis would be potential mental distress or illness with one of the more likely causes being stress or anxiety. It could very well be that the headaches are due to stress due to things like pressure to succeed in school, bullying and so forth (Mount Sinai, 2016). This is probably not the case here given that the child is getting good grades and her excessive computer use if probably what is causing her headaches. However, if computer use adjustments or migraine use does not help, a mental health screening and ascertaining whether the child is under mental duress for any reason might be wise. It would be good to at least ask during this initial visit but the other two diagnoses should be looked at first.
The likely best approach here is to do the following:
Highly advise that computer/phone time be limited
If that is not possible (or not likely to happen), then an eye check and computer glasses might be a good way to mitigate the headaches and other symptoms caused by the use of the devices
Ask the child if she is stressed out, anxious or otherwise in distress (other than the headache issue)
Educate about using good posture and not slouching, laying in awkward positions and so forth when using a computer device for any extended amount of time
Check the eyes for redness or any other apparent issues
Check her blood pressure and pulse levels
Ask the mother if there have been any mental health concerns, addressed or not, regarding the girl
Discreetly advise mother that her extensive use of electronics is probably fairly harmless but to keep an eye on her for mental/habit issues. Keeping an eye on her online activity would be a good idea but it should be done discreetly.
In the end, it would seem extremely likely that the girl is using electronics too much, she needs to better use/protect her eyes or she should improve her posture. The fact that she was so enraptured with her phone during the visit is a cause for concern so that is why the mental health questions do matter. This is especially true given that her father has a rather nasty mental health disorder. Overall, this is a case of an excessive/bad habit or it is a mental health issue. Either way, it can be addressed.
Mayo. (2016). Migraine – Mayo Clinic. Mayoclinic.org. Retrieved 25 January 2016, from http://www.mayoclinic.org/diseases-conditions/migraine-headache/basics/definition/con-20026358
Mount Sinai. (2016). Headache Triggers – The Mount Sinai Hospital. The Mount Sinai Hospital. Retrieved 25 January 2016, from http://www.mountsinai.org/patient-care/service-areas/neurology/areas-of-care/center-for-headache-and-pain-medicine/headache-triggers
Newcomer, L. (2012). How to Avoid Computer Eye Strain — TIME.com. TIME.com. Retrieved 25 January 2016, from http://healthland.time.com/2012/09/13/computer-eye-strain-explained-and-how-to-avoid-it/
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