Case study 1_pediatrics

CASE_STUDY_GUILD_638.docx

NUR 638 – CASE STUDY FORMAT

CC: (6yo male with cough X 1 week)

HPI – history of present illness. This is subjective data that the patient or parent is telling you about the illness. It is the “story” of why the patient is coming to see you, include anything that is relevant (such as co-morbidities).

Example: 5yo female with history of asthma brought to the clinic by mother for c/o cough for 5 days, worse at night. Cough sounds barky. Mother also reports the patient is wheezing and short of breath when engaging in activity. Also has a runny nose and sore throat. Had a fever of 102 yesterday but none today. Cough is worse at night. Drinking well, urinating normally. Siblings are also sick.

PMH – past medical history (include gestation, ie. prematurity and delivery problems if pertinent)

Surgical history

Family history

Medications (name of medication, dose, indication) use prescriptive format

Immunizations

Social or Home situation – who do they live with, siblings, pets (pertinent for respiratory or allergy complaints), smoking. For the well visit you would go over the developmental milestones.

ROS-review of systems: review all of the pertinent body systems (even if you covered it in the HPI). For the well visit, you will need to do a complete ROS.

Physical exam: complete if a well child, pertinent systems for a specific complaint. However, EVERY patient should have a Respiratory and Cardiovascular assessment. You will include vital signs and the results of any diagnostic testing.

Include age appropriate developmental assessment, including milestones and stages.

Differential Diagnoses: What disease do you think is causing the symptoms? List your primary or working diagnosis first. Include 3 differentials with supporting pathology. You can put pertinent positives and negatives to support your diagnosis.

Plan of Care: Include everything that you will do for this patient. Medications, written in prescriptive format (dose, route, frequency, duration, indication). Any lab work or diagnostic testing that you will order. Non pharmacologic therapies. Patient teaching including things the patient can do to prevent disease transmission, symptoms that you would want the patient to watch for and what to do if they occur. Follow up directions – including a time frame and who/where they should go. Remember for your Well Visit you will need to discuss anticipatory guidance!

Reference your sources using APA format. Use your advanced practice journal article for pathophysiology or treatment plan information for the diagnosis.

Follow the grading rubric. Some of these case studies will be long. As always, speak to your assigned faculty if you have any questions.

CaseStudy_Sample_ade.docx

7

History:

CC: 3-year-old. Male with R. Eye Redness x 4 days.

HPI: Z.O. is a 3-year-old M with no significant PMH who presents to the office for a sick visit—accompanied by his mom. Mom complained of redness in the Right eye for 4 days. Mom reports that the patient started c/o clear drainage, pain in the Right eye 4 days ago and noticed redness 2 days ago accompanied by itching. She applied warm compresses and has been given cetirizine for 2 days now with no improvement. Mom denies any contact with anyone who has pink eye. Denies yellow drainage, crusting eye, and closing of the eyelid. Denies any cold symptoms. Denies any visual changes or trauma to the eye. The patient has remained afebrile. He has average oral intake and urine output. Pt currently goes to Head Start, but there is no report of any student with pink eye. Z.O. has no active medications or known drug or food allergies.

Diet: He likes to eat Somali food, pizza, rice, and vegetables.

Elimination: He is fully potty trained.

Sleep: Pt Sleep from 10 pm- 7 am

Behavior: Social interaction is age-appropriate. Once the patient becomes familiar with the situation, he will make friends in new places—no concerns from school or parents.

Development: The child paid appropriate attention and was involved in the exam. Developmentally appropriate.

Speech: Child speech is developmentally appropriate, spontaneous, smooth, and articulate. The primary language in the family is English, and the child speaks English.

Social hx: Z.O. lives with his Parent and two sisters. Like to play with his sibling. Also in head start and participate in class with friends. Home is smoke-free and pet-free

PMH : Mom reports full-term birth with no complications. No surgical history. No significant family history. No active medications.

Immunizations reviewed and up to date.

ROS:

General: Healthy-appearing, well-nourished, and alert child.

Skin: Denies skin, hair, and nail symptoms.

HEENT: No history of head injury. Eyes: Reports erythema of the R. Eye and mild swelling. Ears: Hearing good. No tinnitus, vertigo, infections. Nose: No hay fever or sinus trouble. Throat: No tooth pain or gum bleeding.

Neck: No lumps, goiter, pain. No swollen glands.

Cardiovascular: No chest pain, palpitations, dyspnea, orthopnea.

Respiratory: No cough, wheezing, shortness of breath.

Physical exam:

Vitals: T: 98.7 Wt: 33lb 3oz Wt kg: 15.054 Pulse: 105 Resp: 25 O2SatR: 99

General: Healthy appearing child. Well-nourished and alert. Weighs within the normal range. Mucous membranes are moist and pink. Respiratory pattern is unremarkable. No grunting or nasal flaring.

Head and face : The size of the skull is developmentally appropriate and is in proportion to the rest of the body. Facial move symmetrically and are midline. There is no evidence of dropping, asymmetry, or disproportionate features.

Eye: The conjunctivae show clear white discharge, erythema, and mild swelling in the right eye. The pupil is equal, round, and reactive to light and accommodation. The sclera is clear and anicteric. There is no pain with extraocular movement. Left eye: No abnormalities are noted in the left eye; it appears unaffected.

Neck : Palpation reveals no lymphadenopathy, swelling, or tenderness. No nuchal rigidity

Respiration: exhibits normal structure without evidence of curvature or protrusions. Respiration is regular at a rate of 20 bpm. Lungs are clear bilaterally.

CV: Rhythm is regular. No heart murmur was appreciated.

Neuro: Reflexes are present and symmetric. Cranial Nerves: No sign of apparent neurological deficit.

Developmental milestones : Industry and inferiority. Z.O. is becoming more independent. Feeling confident with accomplishments in school.

Differential diagnosis

DD#1: Allergic Conjunctivitis. Pathophysiology: The conjunctiva is a delicate mucous membrane that can become inflamed or infected from a bacterial or viral infection, allergen, chemical agent, or physical irritant. The infection or irritation can cause dilation of the conjunctival vessels, which leads to the classic red eye and edema of the conjunctiva. The symptoms of conjunctivitis can affect one or both eyes depending on the causative agent. Other symptoms include a scratching or burning sensation, photophobia, discharge, or exudate. The discharge can be purulent or watery depending on the cause (Brady et al., 2020). Positive: Conjunctivitis can affect only one eye. Mum reports erythema and mild edema to the right eye only. Negatives: Clinical exam reveals no erythema and crusting or yellow discharge. Mum denies visual changes like photophobia.

DD#2: Preseptal cellulitis Pathophysiology: Preseptal cellulitis reflects an infection anterior to the orbital septum and does not involve the orbit or other eye structures. The common bacterial cause is streptococcal organisms and staphylococcus aureus. It can also be associated with trauma, foreign bodies, infected lacerations, insect bites, or impetigo, where the infection spreads through the lymphatic channels (Brady et al., 2020). Positive: Preseptal cellulitis is confined to the soft tissues anterior to the orbital septum—no evidence of orbital involvement found on clinical exam. Negative: Pt denies trauma or injury from a foreign body.

DD # 3 : Dacryocystitis. Pathophysiology: Dacryocystitis is an inflammation of the involved nasolacrimal duct that can lead to infection. It is common in neonates, but it can occur at any age due to trauma to the duct or a chronic duct obstruction from an upper respiratory illness. Also, it is found more frequently in those with craniofacial disorders and Down syndrome (Brady et al., 2020). Symptoms include tearing, stickiness, tenderness, swelling over the lacrimal duct, blepharitis in lids and lashes. Positive: swelling of tissues surrounding the eye.

Negative: No purulent discharge, stickiness to lids and lashes, or tearing. Pt denies a history of trauma or URI symptoms—no medical history of craniofacial disorder..

Pharmacology intervention

· Olopatadine 0.1%: Ophthalmic: Instill one drop in each eye twice daily for eye irritation.

Non-pharmacology intervention

· Patients should not rub their eyes because rubbing can cause mechanical mast cell degranulation and worsening symptoms.

· Cool compresses can help reduce eyelid and periorbital edema.

· Frequent use of refrigerated artificial tears throughout the day can also help dilute and remove allergens.

· Avoidance or reduction of contact with known allergens and appropriate reduction of environmental exposure

· Educate on proper hand hygiene

Monitor Symptoms

· Ensure that the redness and swelling gradually improve over the next few days.

· If the eye becomes more swollen or painful, or if the child starts developing a fever, these may indicate a more severe condition (e.g., preseptal cellulitis or a secondary infection).

· If the child complains of blurry vision, light sensitivity (photophobia), or an abnormal pupil, seek medical attention immediately.

Follow-Up

· As recommended, schedule a follow-up appointment in 3 days to reassess the eye. If the condition does not improve by then or if symptoms change, further evaluation may be necessary to rule out other conditions like preseptal cellulitis or dacryocystitis.

· If the patient develops a fever, worsens pain, or the redness spreads to the other eye, call your healthcare provider immediately or seek urgent care.

Reference:

Burns, C. E., Blosser, C. G., Brady, M. A., Dunn, A. M., Garzon, D. L., & Starr, N. B. (2017). Pediatric primary care. Elsevier.

Dupuis, P., Prokopich, C. L., Hynes, A., & Kim, H. (2020). A contemporary look at allergic conjunctivitis. Allergy, Asthma & Clinical Immunology, 16(1). https://doi.org/10.1186/s13223-020-0403-9

Feeney, Susan, & Fitzgerald, M. A. (2017). Pediatric Physical Assessment (tenth). Fitzegrald Health Education Associates, LLC.