cat sheet Family M
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xxxx_AQ1_09192022_FamilyMedicine2112-year-oldfemalewithInfluenzaandfever.docx
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Family Medicine 21:12-Year-Old Female with Influenza
Name xxx
United State University
Course xxxx
Dr. DeRidder
September 19, 2022
Family Medicine 21 12-Year-Old Female with Influenza
Patient History of Present Illness
CAT Essay
Student's Name: xxxxx Case ID: Family Medicine 21: 12-year-old
Influenza J10. 1 ( Cash & Glass, 2017) is the most likely diagnosis for Marissa Payne, a 12-year-old patient,presented with complains of cough, fever, sore throat, muscular pains, and headaches for 3 days now. She denies contact with any sick person. Physical examination reveals a hyperemic oropharynx, intermittent wheezes, and widespread rhonchi, but no crackles in the cervical lymphadenopathy. She reported not being vaccinated against influenza or COVID-19.
Differential Diagnosis
· The major diagnosis here is influenza (J10. 1 )
· Alternative diagnosis: Acute Bronchitis (J20. 9)
· Alternative diagnosis: Group A Streptococcal pharyngitis (J02. 0)
Diagnostics include –
· Rapid influenza diagnostic test (RIDTs)
· Rapid test for group A Streptococcus
· SARS-Cov-2 Rapid Antigen test
· Lipid profile
· Comprehensive metabolic panel (CMP
· CBC, and TSH. These diagnostics test will be conducted to rule out Patient’s condition ( Cash & Glass, 2017).
·
The treatment plan includes
· Oseltamivir or Zanamivir 75 mg orally daily x 5 days ( patient may still benefit from this medication eventhough sickness started 3 days ago.
· Ibuprofen 400mg PO every 8 hours PRN for pain
· Tylenol 650mg PO PRN every 6 hours for fever greater than 100 degrees F (Arnold & Nizet, 2018).
· Home remedies includes gagling with salt and water, use of honey and lemon in your teas ( Cash & Glass, 2017).
Patient Education
Patient education on how to reduce the spread of infectious diseases, such as by washing hands often, wiping the nose and mouth while sneezing, and resting at homes until complaints have faded (CDC, 2022). Insight into the risks of passive smoking (CDC, 2022). Tobacco smoking may aggravate respiratory illnesses such as influenza and bronchitis (CDC, 2022). Physical activity with a healthy diet: Marissa's BMI is much over the 95th percentile, making her clinically obese. Children who have elevated cholesterol or low LDL levels should start a fitness routine (Enkhmaa et al., 2018). Marissa's elevated cholesterol level was 185 mg/dl, much over the recommended level of 170 mg/dl (Enkhmaa et al., 2018). She did not need medication for her LDL cholesterol level (120mg/dl) since it was in the average limits.
Consult
Dietician or nutritionist, reason obesity: Consultation with a nutritionist or dietician. Certain food in the school's menu or at home menu are likely to contribute to the development of obesity in other students (Kim et al., 2019). She needs guidance on how to eat healthily and watch for any problems as a consequence. The issue of obesity will be tackled in this manner.
Follow Up :Return to the clinic if symptoms influenzer persist , otherwise, follow up routine appointment in three month.
References
Arnold, J. C., & Nizet, V. (2018). Pharyngitis. In Principles and Practice of Pediatric Infectious Diseases (pp. 202-208.e2). Elsevier. https://doi.org/10.1016/b978-0-323-40181-4.00027-x
Cash, J., & Glass, C (2017). Family practice quideline (4th ed.). Springer Publishing Company, LLC.
CDC. (2019, November 12). Rapid influenza diagnostic tests. Cdc.Gov. https://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm
CDC. (2022). Influenza antiviral medications: Summary for clinicians. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
Clinic Cleveland. (n.d.). The common cold and the flu. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/13756--colds-and-flu-symptoms-treatment-prevention-when-to-call
Enkhmaa, B., Surampudi, P., Anuurad, E., & Berglund, L. (2018). Lifestyle changes: Effect of diet, exercise, functional food, and obesity treatment on lipids and lipoproteins. MDText.com. https://www.ncbi.nlm.nih.gov/books/NBK326737/
Jovinally, J. (2021, January 22). 11 Cold and Flu Home Remedies. https://www.healthline.com/health/cold-flu/home-remedies
Kim, H. S., Park, J., Ma, Y., & Im, M. (2019). What are the barriers at home and school to healthy eating?: Overweight/obese child and parent perspectives: Overweight/obese child and parent perspectives. The Journal of Nursing Research: JNR, 27(5), e48. https://doi.org/10.1097/jnr.0000000000000321
Lee, Y., & Siddiqui, W. J. (2021). Cholesterol Levels. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542294/
Case Analysis Tool Worksheet
Student's Name: xxxxx Case ID: Family Medicine 21: 12-year-old female with fever
I. Epidemiology/Patient Profile
|
Marissa Payne is a 12-year-old with complaints of fever and cough. |
II. Prioritized Cues from Hx and PE. (Do not include lab, x-‐ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of most minor importance (list only positive cues).
Tier 1 Tier 2 Tier 3
III. Problem Statement
|
Marissa Payne is a female patient who is 12 years old and has complaints of cough, fever, sore throat, muscle aches, and headaches over the past three days. She has not had contact with a sick person. There are no crackles in the cervical lymphadenopathy, but there is a hyperemic oropharynx, occasional wheezes, and generalized rhonchi on physical examination. She has not been immunized against COVID-19 or the influenza virus. Centor score is 3/5 Febrile +1, Antherio cervical lymphadenopathy +1, Age less than 15 years +1 |
IV. Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s).
List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.
Leading dx:
|
Influenza (J10. 1) |
History Finding(s) Physical Exam Finding(s)
|
Acute Bronchitis (J20. 9) |
History Finding(s) Physical Exam Finding(s)
|
Experiencing muscle aches and pain all over. |
Body temperature is 100.9 °F O2sat: 97% RR: 22 breaths per minute BP: 110/70mmHg Weight: 60.3 kg (133 lbs) Height: 152.4 cm (60 in) |
|
Has sore throat |
Nose turbinates are swollen and clear mucus is coming out. |
|
Reports fever and cough |
No murmur is appreciated since the heart sounds normal. |
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Experiences headaches |
|
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Occasional wheezing |
|
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Loss of appetite |
|
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She is taking guaifenesin and ibuprofen for cough and fever, respectively. |
|
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She has not had a flu shot or a SARS-CoV2 vaccine this year. |
|
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No history of respiratory issues, pneumonia, or heart disease. |
|
|
|
|
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She does not smoke tobacco but secondhand smoke at home |
|
Alternative dx:
|
Group A Streptococcal pharyngitis (J02. 0) |
History Finding(s) Physical Exam Finding(s)
|
Experiencing muscle aches and pain all over. |
Body temperature is 100.9 °F O2sat: 97% RR: 22 breaths per minute BP: 110/70mmHg Weight: 60.3 kg (133 lbs) Height: 152.4 cm (60 in) |
|
Has sore throat |
General: Patient appears to be sick but not toxic Eyes: PERRLA Ears: Bilateral external canal and tympanic membrane is pearly gray. Nose turbinates are swollen and clear mucus is coming out. Mouth: Hyperemic oropharynx with tonsillar exudates absent Neck:Painful anterior cervical lymphadenopathy on both sides Respiratory: Movement of the chest is symmetric, normal breathing. On inspiration rhochi sound is ascultated, no wheezing or crackle noted. Expiratory phase is not prolonged. No dullness in percussion. |
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Reports fever and cough |
|
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Experiences headaches |
|
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Loss of appetite. |
|
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She has not had a flu shot or a SARS-CoV2 vaccine this year. |
|
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She is taking guaifenesin and ibuprofen for cough and fever, respectively. |
|
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No one in her class has been sick. |
|
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No history of respiratory issues, pneumonia, or heart disease. |
|
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Occasional wheezing |
|
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She does not smoke tobacco but secondhand smoke at home |
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V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s).
Diagnostic Plan Rationale
|
Rapid influenza diagnostic test (RIDTs) |
The goal of this test is to confirm the presence of influenza (CDC, 2019). Positive results |
|
Rapid test for group A Streptococcus |
Streptococcal Pharyngitis can be ruled out with this test. Negative results |
|
CBC |
To rule out any abnormalities with any white blood cell. |
|
Lipid profile test |
The Lipid Profile consists of the following: Total cholesterol, High-density lipoprotein, as well as Low-density lipoprotein (Lee & Siddiqui, 2021). This test helps in assessing cholesterol and lipoprotein abnormalities caused by obesity (Lee & Siddiqui, 2021). |
|
SARS-Cov-2 Rapid Antigen test |
These diagnostics test are an essential part of global screening initiatives to control pandemic. Negative result. |
Treatment Plan Rationale
|
Influenza medication · Oseltamivir or Zanamivir 75 mg orally daily x 5 days · Ibuprofen 400mg PO every 8 hours PRN for pain · Tylenol 650mg PO PRN every 6 hours for fever greater than 100 degrees F
|
So far, Marissa's situation does not warrant the use of influenza medications like Oseltamivir or Zanamivir because they are only suggested for use within the 48 hours of the onset of the symptoms (CDC, 2022). In this case, ibuprofen and acetaminophen are recommended for pain and fever treatment, respectively (Clinic Cleveland, n.d.). In addition, honey and lemon might be taken by the patient. Coughs and sore throats may be lessened and soothed with honey and lemon, according to several studies (Jovinally, 2021). |
|
Patient education |
Educating the patient on how to prevent virus transmission by cleaning the hands, covering the nose when sneezing, and remaining home from school until the symptoms have subsided (CDC, 2022). Education on the dangers of secondhand smoke exposure (CDC, 2022). Influenza and bronchitis could be exacerbated by smoke. |
|
Exercises and a balanced diet |
Marissa is obese because her body mass index (BMI) is greater than the 95th percentile (Enkhmaa et al., 2018). An exercise plan is recommended for kids with high cholesterol or low LDL (Enkhmaa et al., 2018). In Marissa's case, her cholesterol was 185mg/dl, which is beyond the normal range of 170 mg/dl. Her LDL level (120mg/dl) was within the normal range, so she did not require any medical treatment (Enkhmaa et al., 2018). |
|
Referral to Dietician |
Referral to a dietitian. Some of the meals in the school's home dietary pattern are unhealthy and could lead to obesity in other children (Kim et al., 2019). As a result, she requires assistance managing her weight and diet, as well as identifying any issues that may arise. Obesity will be addressed in this way. |
|
Follow-up |
Return to the clinic if symptoms influenzer persist , otherwise, follow up routine appointment in three months.
|
I have adhered to the honor system: ____Name ___________________________
(Students Signature)
References
Arnold, J. C., & Nizet, V. (2018). Pharyngitis. In Principles and Practice of Pediatric Infectious Diseases (pp. 202-208.e2). Elsevier. https://doi.org/10.1016/b978-0-323-40181-4.00027-x
CDC. (2019, November 12). Rapid influenza diagnostic tests. Cdc.Gov. https://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm
CDC. (2022). Influenza antiviral medications: Summary for clinicians. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
Clinic Cleveland. (n.d.). The common cold and the flu. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/13756--colds-and-flu-symptoms-treatment-prevention-when-to-call
Enkhmaa, B., Surampudi, P., Anuurad, E., & Berglund, L. (2018). Lifestyle changes: Effect of diet, exercise, functional food, and obesity treatment on lipids and lipoproteins. MDText.com. https://www.ncbi.nlm.nih.gov/books/NBK326737/
Jovinally, J. (2021, January 22). 11 Cold and Flu Home Remedies. https://www.healthline.com/health/cold-flu/home-remedies
Kim, H. S., Park, J., Ma, Y., & Im, M. (2019). What are the barriers at home and school to healthy eating?: Overweight/obese child and parent perspectives: Overweight/obese child and parent perspectives. The Journal of Nursing Research: JNR, 27(5), e48. https://doi.org/10.1097/jnr.0000000000000321
Lee, Y., & Siddiqui, W. J. (2021). Cholesterol Levels. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542294/
Luo, R., Sickler, J., Vahidnia, F., Lee, Y.-C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group a streptococcal pharyngitis in the United States, 2011-2015. BMC Infectious Diseases, 19(1), 193. https://doi.org/10.1186/s12879-019-3835-4
Mayo Clinic. (2021, November 1). Influenza (flu) - Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/flu/symptoms-causes/syc-20351719
Singh, A., Avula, A., & Zahn, E. (2022). Acute Bronchitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/
