Mercy NURS775 Pediatric Case Study Week 4 Latest 2022

Case Studies:  5-year-old male

 

 

 

Informant:                  Mrs. Lovely

 

 

 

Child:                          5 year old Reily (male)

 

 Day/Time:                   Monday; 10 am

 

CC:                   5-year-old male presents with  mother for well child visit & follow up

 

                        From ER visit this weekend for asthma and fever

 

 

 

Interim History

 

Has been doing well since last visit with one or two mild episodes asthma – which were controlled at home with albuterol nebulizations/pump   until this Saturday when he developed a fever and cough and became short of breath even after 4 nebulizer treatments at home, at 2 pm on Saturday he was noted to have a fever of 101.2 and had a febrile seizure which consisted of tonic/clonic movements of all extremities and lasted a few minutes. He was taken to the ER where he was evaluated; received 3 more treatments and one dose of prednisone and was d/c’d home with diagnosis of URI and Asthma.  Since Saturday he continues to cough and wheeze and is taking albuterol nebs q 4 hours as well as his prednisone as ordered.  He last had a temperature of 100.9 this morning.

 

 

 

Past Medical History:

 

 

 

Prenatal/Natal:

 

Born at 39 weeks to a 41 year old G1 P0000 via C-section due to failure to progress; conceived via IVF after 3 years of infertility medications with no results

 

Birth Weight: 3.9 kg

 

Prenatal care started @ conception

 

No complications with delivery

 

D/c’d on day of life #2

 

 

 

Neonatal:

 

            Breast-fed exclusively till 6 months of age- began juices and baby food

 

            + Bronchiolitis at age 4 months – admitted for 2 days for monitoring

 

 

 

Illnesses:

 

+ Asthma- diagnosed @ about 2 years of age, + admission for asthma @ 2 years no ICU admissions; no intubations, + history of steroids- last one prior to now 6 months;

 

1 OM at 8 months of age;

 

 + history of febrile seizures since 1 year of age- has had 3 febrile seizures since then

 

Eczema

 

 

 

Accidents:  + nursemaid’s elbow @ 10 months of age

 

 

 

Hospitalizations: As above for Bronchiolitis/asthma

 

Immunizations:  as per mom- will bring documentation next visit

 

 

 

Allergies: Amoxicillin (rash)

 

Medications: 

 

Albuterol nebs q 4-6 hours prn

 

            Albuterol pump q 6 hours prn with spacer

 

            Prednisone 60 mg once a day (on day 3/5)

 

 

 

Nutrition:

 

Described as “good eater”; eats almost anything that the family eats:

 

            24 hour recall:

 

                        breakfast:  bowl of cherrios, sliced apples; pop tart

 

                        Snack: pretzels, and soda

 

                        Lunch: grilled cheese sandwich; glass of whole milk

 

                        Snack: Brownies

 

Dinner: raviolis and peas, milk; ice cream &sugar cookies for desert

 

 

 

Social/Environmental

            lives in suburban upper-middle class neighborhood

 

House was built in 1960’s; 4 bedrooms with large backyard on a lake, lives with mother, father and family dog; father + smoker- but not in house- only out on patio; park is nearby, no rodents or peeling paint; grandparents live 2 hours away and visit once a month

 

 

 

            Activity:

 

Very active as per mom; lives to play outside, watches about 1 hour of TV a night; uses computer prior to going to bed; has a group of friends from neighborhood ranging from 3 ½ to 5 years old; recently registered to start cyo soccer camp in summer (2 months from now)

 

 

 

            Sleep:  sleeps in bed with his favorite toy “Thomas the train” (stuffed)

 

                        Sleeps from about 8:30 pm to 7 am

 

May fall asleep sometimes in afternoon when he’s been outside a lot in the morning

 

 

 

            Elimination:  

 

Bladder trained 3 yrs 2 months- but has always had occasional accidents- used to be during day when playing, for past year has about 4 episodes per month of wetting bed at night, mom is concerned because he is now asking to have sleep over at his friend’s house but she is worried if he wets the bed it will embarrass him

 

 

 

Bowel trained: @ 3 ½ years of age; denies problems with constipation: has regular BM q other day in morning

 

 

 

            Growth and Development:

 

 

 

                        Smiled @ 3 weeks

 

                        Sat @ 8 months

 

                        Walked @ 15 months

 

                        Drank from cup @ 18 months

 

                        First intelligible words @ 20 months

 

                        Speech is 90% intelligible to strangers- still has trouble with “L’s”

 

                        Recently started stuttering at school

 

Can dress self with help for buttons and zippers, does not ties shoes

 

Jumps hops & skips

 

Can draw circle and cross & square

 

Draws person with 2 parts (demonstrated)

 

Difficulty with heel-toe walk

 

Can balance on one foot for 10 seconds

 

Jumps, and skips

 

 

 

 

 

            ROS:

 

 

 

General:          mom describes him as an alert, happy active 5-year-old who recently began to stutter occasionally when he is upset or excited, loves to run and play; over past few days with fever has seemed a bit more tired but is still playful at times

 

 

Skin                 hx of eczema but mom denies any current active rashes

 

 

 

HEENT:          

 

Head: denies any headache, no history of head trauma or injury

 

Eyes: + red eyes with recent illness and itching a lot ; vision testing was done in preschool- as per mom (not totally sure)

 

Ears:   No c/o ear pain, no ear d/c, cleans ears with q-tip and hydrogen peroxide after each bath

 

Nose   for past 2 days + green rhinorhea + snoring with sleeping over past few days

 

Throat   c/o sore throat since yesterday, able to swallow, brushes teeth by himself; + sucks his thumb to fall asleep; no dental carries thus far- one visit to dentist 6 months ago

 

 

 

Chest:

 

                        + history of cough for past few days and with colds and asthma; has been taking asthma meds as previously stated, took Robitussin last pm due to coughing and congestion interrupting his sleep; no shortness of breath today, + mild coughing improves after treatments, + one episode on Saturday of post tussive vomiting, none since then; no history of heart murmur or chest pain

 

 

 

Abdomen:

 

                        + one episode on Saturday of c/o abdominal pain before episode of post-tussive vomiting; no diarrhea, decreased po intake of food but takes juices/water well

 

 

 

GU

 

                        + urine output, no dysuria, no frequency

 

 

 

MS                   likes to run; play; no complaints of muscle/joint pain, climbs well

 

 

 

Neuro:            started to stutter about 2 months age- worse when he is frustrated; excited or upset; no other changes in language; alert and active as per mom

 

 

 

Physical Exam:

 

 

 

                        Temp  100.8 po  HR 110          RR 28  Wt: 32 kg  Ht 116 cm

 

 

 

General: alert 5 year old mildly ill appearing; playing with toy car on table

 

Skin                 2 cm x 2 cm circular area of hair loss with scaly appearance to posterior occipital region of scalp;

 

HEENT:          

 

 

 

Head               NCAT, symmetrical facies

 

Eyes:                conjunctiva pink with sclera injection, + clear d/c, PERRLA; disc margins sharp; no papiledema, EOMI, vision: OU 20/30; OS 20/30 OD 20/30;

 

Ears:                Bilateral TM’s pearl grey; + light reflex bilaterally; + landmarks; + small effusion noted to upper aspect of L TM; + mobility bilaterally; hearing test unable to be completed- machine broken

 

 

 

Nose:               nares patent, small amount crusted green rhinorhea noted to bilateral nares; turbinates: erythematous and slightly hypertrophied

 

Throat/Mouth:           posterior pharynx erythematous, tonsils +2 with no exudate or petechiae; uvula midline, teeth without dentition noted; + mucous membranes moist

 

 

 

Chest:              Lungs with end expiratory wheezing noted bilaterally with slightly decreased air entry to bilateral lower lobes; no retractions, no nasal flaring, no rales

 

 

 

Heart               Heart rate regular, S1 and S2 audible, no murmur ausculated

 

 

 

Abdomen:      protuberant, soft + bowel sounds, no masses, no pain with palpation, no HSM, no CVA tenderness

 

 

 

GU:                  Testes descended bilaterally, circumcised penis with urethra midline, Tanner I

 

 

 

MS:                  walks well, spine symmetrical with no dimples/hair tufts; jumps on 2 feet but cannot hop on one foot; skips, full ROM of all extremities; no swelling to extremities;

 

 

 

Neuro             Alert; speech clear with occasional words difficult to decipher; occasional stutter noted; alert and oriented to person and place, reflexes +2 to all extremities; balance normal; gait normal; muscle strength 5/5 bilaterally

 

 

 

Working up the differentials & treatment for each differential

 

 

 

Physical exam

 

Concerns?

 

Diagnoses

 

Labs/tests

 

Treatment plan for diagnosis

 

•      Medications

 

•      Education

 

•      referrals

 

 

 

Well Child Visit

 

Immunizations

 

•      To be given today

 

Screening/tests

 

•      To be done based on this visit

 

•      Anticipatory guidance 

 

•      Developmental assessment

 

•                  Is infant meeting milestone

 

•      Social & emotional

 

•      Language

 

•      Cognitive

 

•      Gross motor/fine motor

 

•      Nutrition

 

•      Sleep

 

•      Elimination

 

•      Safety/injury

 

•      Social Determinants of health

 

•      Referrals

 

•      Follow up visits