Case Study MN581

Primary Care Pediatric Case Study

Introduction: Anne is a 14 year old female who presents to the primary care pediatric clinic with her mother.

CC “I am tired all the time”

HPI

Anne reports symptoms began around six months ago. Symptoms have progressed over this time. Anne reports that over the past two months she began making “bad grades” in school. She reports that she doesn’t have the energy to study as much as before. Anne denies cough, fever, night sweats, weight loss, weight gain, bleeding other than menses, nausea, vomiting, pain, syncope, headaches, or vision/hearing problems. Anne denies sexual activity, contraception use, burning upon urination, menstrual cramps, and vaginal discharge. Anne denies anything that improves or worsens symptoms. Anne’s mother reports that over the last 6 months Anne has gradually stopped participating in sports, complains frequently of fatigue, and not feeling rested after sleep. Sometimes Anne does not want to go to school. Her mother confirms that Anne’s school grades have dropped. Her mother reports that before these current symptoms Anne made excellent grades, actively participated on the school’s volley ball team, and was engaged in many social activities and clubs.

Social Hx: Anne is in the 10th grade. She lives in a small home with her mother who is divorced and works full time. The household has one cat. There is nobody else that resides there. Ann reports having a “good” relationship with her mother and they “are very close.” Anne does not have any siblings. Anne reports having a best friend and several “kids” that she hangs out with. Anne denies being sexually active. She denies any tobacco, ETOH, or other illicit substance use. Ann’s appetite is good and, since her mother sometimes works late, her diet is frequently fast foods, pizza, and sweets. Anne has always been “physicaly active in sports” prior to her current symptoms.

Family Hx: Anne’s mother denies any family history of bleeding disorders, diabetes, or endocrine disorders. Anne’s grandfather is deceased from heart disease. Anne’ grandmother is alive and in good health. Anne’s biological father has DM type two and hypertension.

Medications: Occasional Tylenol or ibuprofen. No prescribed medications. No vitamins or herbal remedies.

Allergies: NKA

PMH: Her mother reports that Anne was born at 39 weeks gestation as a healthy newborn without any abnormal findings. She was breast fed the first 6 months and transitioned to iron fortified formula. Anne’s routine lab monitoring has been in normal ranges. Anne’ s growth and development has been in the 50th percentiles and expected milestones were met in infancy and early childhood. Anne’s immunizations are up to date and she receives influenza vaccines yearly.

Anne and her mother report that Anne has had several “colds” and two ear infections while in elementary school. Ann and her mother deny any hospitalizations, surgeries, major injuries, or illnessess.

LMP was 15 days ago with the following characteristics:

· Age of menarche: 11 years old

· Frequency: approximately every 20 days

· Regularity: No missed menses. Regular every 20 days or so

· Duration: usually 8 days

· Volume of flow: approximately 5-7 sanitary pads per and “heavy” flow

Physical Examination

Vital Signs/ Height/Weight:

· Temperature: 98F

· Heart rate: 120

· BP 100/52

· Wt: 105.0 lb (47.6 kg)

· Ht 62.5" (158.7 cm)

General: Well developed, well nourished 14 year old female who appears her stated age. Patient is in no acute distress. Speech and cognition are within normal range for age.

Skin: Pale without any rashes, lesions, bruises, lacerations, or discolorations.

HEENT: Vision field is normal. Fundoscopic exam reveals sharp disc margins, no hemorrhages, normal AV ratio. Pharynix is clear without redness or swelling. Tonsils +1/+1 no exudate and no erythema.

Heart: Tachycardia with regular rate and rhythm. No murmurs. No extra clicks or gallups.

Lungs: Vesicular sounds are clear bilaterally in all lobes. No wheezes, rubs, rales, or rhonchi.

Female sexual

maturity rating: Tanner stage 4

Extremities: Present and equal peripheral pulses. No swelling, tenderness, or deformities.

ABD: Soft and nontender in all four quadrants. No distention or masses. BS present in all 4 quadrants.

Neurological: Cranial nerves intact. Peripheral reflexes +3 equal bilaterally

Laboratory Results (normal ranges by age and gender, 14 yo female)

Normal Ranges

Urine HCG negative

Urine drug Screen negative

Hemoglobin (g/dl) ` 9.8 (13.7-12.3)

Hematocrit (%) 30 (40-36)

MCV (fL) 72 (87-80)

Red cell distribution width (RDW) 17.3 (11.5-14)

Red Blood Count (x 106 /µL) 2.9 (3.80-5.20)

Red Blood Cell Indices

· MCV (Fl) 68 (78-98)

· MCH (pg) 18 (21-31)

· MCHC(%) 28 (32-36)

WBC (x 103 /µL) 10.9 (4.5-13.5)

WBC differentials:

· Neutrophils (x 103 /µL) 4.1 (1.5-7.5)

· Lymphocytes (x 103 /µL) 3.2 (1.5-6.5)

· Monocytes (%) 0.4 (0-0.8)

Platelets (x109/L) 426 (150-400)

Total Iron Binding Capacity (TIBC) (mg/dL) 455 (240-450)

Serum iron (mcg/dL) 35 ( 50-170)

Serum ferritin (mcg/L) 9 (11-307)

Follicle-stimulating hormone (FSH)(mlU/m) 3.4 (4.7 - 21.5)

Thyroid Stimulating Hormone (TSH)                   4.0                 (0.5 to 5.0 mIU/L)

Assessment

· Formulate a Problem list for this patient including any abnormal findings on physical exam, history, laboratory, signs and symptoms

· List Differential Diagnoses with rational (why is this a differentia?)

· Which diagnoses are ruled in? (support this with references and patient data)

· Which diagnoses are ruled out? (support this with references and patient data)

· What is your final diagnosis?)

· Describe any abnormal findings on physical examing

Rationales

· Explain why a FSH lab was ordered and what does a low FSH indicate?

· Explain why a TSH lab was ordered and what does an abnormal value indicate?

· Discuss this patient’s blood work and what these may indicate.

· What is are possible causes of this patient’s thrombocytosis?

· What, if any, information is missing?

Plan

Using current, credible, evidence-based practice guidelines formulate a comprehensive treatment plan that includes education, counseling, medications (if any), and any additional recommendations. Include in this plan follow-up information such as when client should return and what assessments, diagnostics, education, etc. will be done.