discussion response
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discussionresponsecasestudy16541.docxHPI: A 14-month-old Native American boy brought in by his mom due to cough, low grade fever and runny nose for the past 2 days. This morning, the mother noted that her son was breathing quickly and “it sounds like he has rice cereal popping in his throat.” Mom is worried because her son seems to have a lot of “bouts of colds”. Per mom, his oral intake is decreased. He didn’t want to eat this morning.
PE: Smiling, alert Native American boy. VS: Temp of 99.9, pulse 112, respiratory rate is 58, Pulse ox 96% HEENT: There is moderate, thick, clear rhinorrhea and postnasal drip. CV: His capillary refill is less than 3 seconds PULM: lung sounds are diminished in the bases, he has pronounced intercostal and subcostal retractions, expiratory wheezes are heard in all lung fields.
Additional questions: Does the child have a history of allergies? He has had a lot of colds recently. How many colds has he had within the past month? How long do his colds last? Has he been exposed to anything new? (food, medications, soaps, animals, etc) Does he have any siblings? Have they had any of the same symptoms? Has he been exposed to anyone recently who has been sick? Is he eating or drinking? Is he urinating?
Location: Upper and lower respiratory tract Other symptoms: Cough, low grade fever, runny nose x2 days, tachypnea, decreased appetite Characteristics: “sounds like he has rice cereal popping in his throat” Alleviating and Aggravating factors: None identified. Would question if there are any alleviating and aggravating factors. Time of symptoms: None specifically identified. Would ask if the symptoms occur more during a certain time of the day? Do they occur after exposure to something specific that seems to trigger the reaction or make it worse? Environment where symptoms occur: None identified. I would ask if the symptoms occur more often in a specific environment such as daycare, home, the store, outside, etc.? Severity of symptoms: None identified. Would ask mother how severe the symptoms are when they occur? Severity of symptoms can be observed with the pronounced intercostal and subcostal retractions, expiratory wheezes, and tachypnea. I would also assess the child for LOC and cyanosis
Additional information: Medications, medical history, birth complications, family history, surgical history
Diagnostic testing: RSV swab, flu swab, chest x-ray. Referral to an allergy specialist if indicated.
Differential diagnosis:
•(Primary) Bronchiolitis: This condition is caused by a virus and there are numerous viral infections that could be the cause. The most common are RSV and rhinovirus. The child presents with a cough, runny nose, and fever for 2 days that progresses into respiratory distress as seen by the subcostal and intercostal retractions, wheezing, and tachypnea. His s/s are a classic presentation of bronchiolitis, which begins as upper respiratory symptoms of cough, rhinorrhea, and fever that develop into lower respiratory s/s of labored breathing, tachypnea, wheezing, and decreased oxygenation on days 2-3 (Burns et al., 2017).
•Community-acquired pneumonia: This respiratory condition may be bacterial or viral. S/s may include fever, cough, tachypnea, and labored breathing, but each child is different and no specific symptom is indicative of pneumonia (Burns et al., 2017). If this child does have pneumonia, it is more likely to be viral. Viral pneumonia presents gradually, precedes upper respiratory symptoms, wheezing is a common finding, and the child appears well otherwise.
•Reactive Airway Disease (Asthma): S/s include coughing and wheezing and are usually brought on by triggers such as seasonal, URIs, exercise, weather, tobacco smoke, allergens, irritant exposures, and stress (Burns et al., 2017). Other symptoms can include tachypnea, hypoxia, labored breathing, and retractions.
Treatment: The child’s weight needs to be obtained to make accurate medication dosage calculations. Based on this child’s s/s and assessment findings, I would recommend that he be admitted overnight for treatment and observation. He is alert and smiling and his SpO2 is currently 96%, however, the severity of his symptoms which include wheezing, subcostal and intercostal retractions, tachypnea, and decreased intake warrant hospital admission (Ralson et al., 2014). The first priority to address is his breathing. Treatment for this symptom would include an Albuterol nebulizer 0.15mg/kg diluted in 2.5 to 3ml normal saline administered over 5 to 15 minutes every 4-6 hours prn (Panitch, 2003), nasal suctioning if necessary (Mussman et al., 2013), and supplemental O2 to maintain an SpO2 >90%. Close monitoring of his respiratory status is important. He would also receive maintenance IV fluids of normal saline for hydration based on calculated daily energy expenditure of the child which is determined by body weight and I would keep the child NPO at first to ensure he doesn’t aspirate due to the coughing and tachypnea (Khoshoo & Edell, 1999). His output would also be closely monitored. Tylenol would be given as well dosed based on weight: 10-15mg/kg/dose every 4-6 hours as needed, do not exceed 5 doses in 24 hours; max daily dose 75 mg/kg/day not to exceed 4,000 mg/day.
Health Promotion:
What immunizations should this child have had? Received: 2 doses of Hep B, Rotavirus series, 3 DTAP, 2 HIB, 3 PVC, 2 IPV
Based on the child’s age, when is the next well visit? 15 month wellness visit.
At the next well visit, what are the next set of immunizations? Immunizations due: MMR, Varicella, Hep A (if not received at 12 month visit), 4th DTAP, 3rd HIB, 4th PCV13, 3rd dose of IPV
What additional anticipatory guidance should be provided today? The family should be educated on ways to prevent the spread of illness and germs, such as frequent hand washing, prohibiting sharing of food and drinks, covering mouth and nose when coughing or sneezing, and frequently disinfecting surfaces that are touched often. Also, the importance of vaccinating children and keeping vaccination schedules should be expressed, as well as recommendations for the flu vaccination when in season. If the child attends daycare, the parents should be educated about being mindful of other children there being sick and keeping there child at home when he is sick as well. Also, avoid exposure to second hand smoke.
Socio-economic factors: Socio-economic status is not given or implied, however, all parents should be asked if they are able to afford their children’s medications, and if their homes have running water, heat, and food. American Indian infants may be administered RSV prophylaxis <12 months of age due to higher rates of RSV hospitalization and the costs associated with transport of these infants from remote locations (Lowther, Shay, Holman, et al., 2000).
References:
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier
Khoshoo, V., Edell, D. (1999). Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis. Pediatrics; 104:1389
Lowther, S.A., Shay, D.K., Holman, R.C., et al. (2000). Bronchiolitis-associated hospitalizations among American Indian and Alaska Native children. Pediatric Infectious Disease Journal; 19:11.
Ralson, S.L., Lieberthal, A.S., Meissner, H.C., et al. (2014). Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134:e1474.
Mussman, G.M., Parker, M.W., Statile, A., et al. (2013). Suctioning and length of stay in infants hospitalized with bronchiolitis. JAMA Pediatrics; 167:414.
