Comprehensive Case Write-Up
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Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm. This assignment should be 6-8 pages single-spaced.
FNP Pediatric Health Comprehensive Care Write Up
Student’s Name
Institutional Affiliations
FNP Pediatric Health Comprehensive Care Write Up
Patient Details
Initials: J.T.
Age: 12 years
Gender: Male
Race: White
Subjective:
CC: “I have a cough that has persisted for the past 2 days. I also experience pain the throat when swallowing food”
HPI:
J.T. is a 12-year-old male white patient who are come to the clinic accompanied by his mother. He reports that he has been coughing persistently and that he also experiences a mild pain in the throat when swallowing food. These symptoms have lasted for 2 days. He further reports a runny nose, headache, sore throat, loss of appetite, and nasal congestion. While the patient is unable to link his other symptoms to any aggravating or relieving factors, he indicates that nasal congestion or stuffiness worsens during cold weather and improves when the weather is hot. The mother reports that he bought OTC Ibuprofen in the morning which he now gives to his son at a dose of 400mg twice daily. J.T. took his first dose in the morning. He further indicates that his son uses warm water and sleeps quite often to help relieve the pain. According to J.T.’s mother, his son was diagnosed with pneumonia at the age of 7 years and he was successfully treated without hospitalization. She further reports that she is also experiencing a mild sore throat which started in the morning.
Past Medical History: J.T. was diagnosed with pneumonia 5 years ago at the age of 7 years. He was successfully treated.
Past Surgical History: The mother reports that his son has not undergone any surgeries before.
Medications: 400 mg of ibuprofen taken orally twice daily to relieve headache.
Allergies: J.T. does not have any medication or food allergies.
Social History: J.T. enjoys playing football with his friends in the neighborhood. He is always active but his current symptoms have affected his level of activity in the past few days. J.T.’s mother indicates that his son received all immunizations according to schedule. The immunizations received up to date include diphtheria, pertussis, and tetanus (DPT) vaccine, measles, mumps, rubella (MMR) vaccine, polio vaccine, 1st and 2nd doses of rotavirus vaccine, and 1st and 2nd doses of hepatitis B vaccine. Other vaccines received so far include hepatitis A vaccine, pneumonia vaccine, and varicella vaccine. J.T. received his last influenza vaccine last month on 15/06/2022 as part of health maintenance. The patient is covered under his parents’ health insurance program. His mother ensures that he sleeps under a treated mosquito net and wears warm clothing during cold weather.
Family History: J.T.’s mother is 39 years old and his father is 42 years old. Both parents are accountants and they are employed in different companies in the city. They do not have serious medical conditions and do not consume cigarettes or alcohol. J.T. has two siblings: a girl aged 9 years and a boy aged 6 years. His siblings have not been diagnosed with any serious medical conditions apart from mild fever and malaria that they were successfully treated from. Maternal grandparents are both alive. As reported by J.T.’s mother, her father has high blood pressure and her mother is healthy. J.T.’s paternal and maternal grandparents are both deceased with little known details regarding their causes of death.
Review of Systems (ROS):
General: Denies fever and fatigue. Denies abnormal weight gain/weight loss. Denies nausea or vomit. Reports loss of appetite. His last medical exam was 1 year ago.
Skin, Hair, Nails: Denies skin rashes or scaling. Denies hair loss. Refutes cracking nails or abnormal coloration of the nail beds.
HEENT:
Head: Denies recent physical head injury. Reports a headache.
Ears: Denies hearing loss.
Eyes: Denies blurred vision. Denies using corrective lenses.
Nose: Reports runny nose. Denies sneezing. Admits nasal congestion and stuffiness during cold weather.
Throat: Admits a persistent cough and sore throat. Reports pain in the throat while swallowing food. Denies lesions in the mouth.
Neck: Denies pain in the neck
Breasts: Denies pain, discomfort, or abnormal masses in the nipple.
Pulmonary: Reports breathing difficulties during cold weather due to nasal congestion. Refutes tightness of the chest. Reports a persistent cough. Denies wheezing. He has a history of pneumonia as reported by the mother.
Cardiovascular: Denies orthopnea, edema, or a history of cardiovascular problems. Denies irregular heartbeat or chest pain.
Gastrointestinal: Reports pain when swallowing food. Refutes abdominal pain, heartburn or indigestion. Denies nausea or vomiting. Denies diarrhea or constipation. Reports loss of appetite. Denies a history of gallbladder issues.
Urinary: Denies pain in the genitals during urination or dysuria. Refutes a reduction in urine volume Denies presence of blood in urine or hematuria. Does not have a history of urinary tract infections as reported by the mother.
Genital tract (male): Denies a history a urinary tract infection. Denies hernias or penile discharge. Refutes pain in the genitalia or swelling in the testicles.
Musculoskeletal: Denies stiffness or swelling on joints. The mother indicates that J.T. does not have limitations of motion or a history of fractures or backache. Denies backache or arthritis.
Neurologic: Reports a headache. Denies facial pain. Denies blackouts or seizures, numbness of limbs, or tremors in the limbs.
Psychiatric: J.T. denies depression or anxiety.
Endocrine: Denies abnormal sweating. Refutes excessive thirst. Denies abnormal increase in urine volume or urination frequency. Denies heat or cold intolerance.
Hematologic: Refutes anemia or blood-related disorders. Refutes blood transfusion history. Denies a history of sickle cell disease.
Objective
General appearance: J.T. is alert and oriented to person, place, and time. He is well groomed and appropriately dressed for the weather.
Vital signs: Height=49 inches; respiratory rate=18; temperature=36.5 degrees Celsius; heart rate=90 beats per minute; weight=62 pounds; Blood pressure=112/60; BMI=18.2 kg/m2.
Physical examination
Skin: Warm and moist. No lesions, no rashes.
HEENT:
Head: J.T.’s head is normocephalic, no masses, atraumatic. No alopecia, no hair thinning.
Eyes: No drooping of eyelids. Conjunctiva is pink, sclera is white. No hemorrhages. Visual acuity 20/20. No evidence of drainage. PERRLA bilaterally.
Ears: No evidence of blockage in the ear canal. No drainage, lesions, or tenderness. Both ears are sensitive to sound stimuli.
Nose & Sinuses: Nasal septum is positioned midline. The nasal mucosa is pink, moist, and hairy. No maxillary or frontal sinus tenderness. Nasal discharge observed.
Throat & Mouth: Oral mucosa is moist and pink, soft lips. Absence of gum inflammation. Throat is erythematous.
Neck: No masses, pain, lesions, or bruits.
Lymphatic: No swelling or tenderness. No Lymph nodes.
Breasts: No lumps or masses. No evidence of pain.
Thorax & Lungs: Trachea positioned midline. No adventitious lung sounds. No crackles, rhonchi, or wheezes. Lungs expand uniformly during inhalation and contract uniformly during exhalation. Normal breath sounds noticed. Clear anterior and posterior lung fields.
Cardiovascular/Peripheral Vascular: S1, S2, without galloping. No murmurs. Visible midclavicular PMI and 5th intercostal region. Capillary refill less than 3 seconds. No edema on the periphery. 2+ carotid pulse bilaterally.
Abdomen: No distention, tenderness, or pain. Abdomen is protuberant and soft. Bowel sounds active in all four quadrants. Palpation does not show any sign of hernia. Liver and spleen are nonpalpable.
Musculoskeletal: No joint stiffness or tenderness on palpation. Lower and upper extremities are atraumatic, no evidence of swelling of the joints. Gait is not impaired.
Genitalia & Rectum (male): No lesions or masses in the penis. No evidence of pain. Non-tender testes. The testes are without lesions. No rectal hemorrhoids observed.
Neurologic:
Mental status: J.T can concentrate and he is attentive. No evidence of language, speech, or memory problems.
Cranial nerves: Intact Crania nerves II-IX. Visual fields observed. Evidence of full EOM.
Motor: Muscle rigidity absent. Muscle strength of 5/5 on all joints. Good balance.
Sensory: Upper and lower limbs have 2+reflexes. All limbs are sensitive to pricking and touch.
Assessment
Primary diagnosis: Common cold
Differential diagnoses:
- Influenza (flu)
- Allergic rhinitis
- Sinusitis
Rationale for Diagnosis
Most upper respiratory complications in pediatrics usually cause symptoms that resemble those displayed by J.T. Persistent cough, headache, sore throat, and nasal congestion are symptoms that are primarily associated with common cold (Pappas, 2018). However, patients with other conditions such as influenza (flu), allergic rhinitis, and sinusitis may also exhibit some of these symptoms. The absence of watery and red eyes in the patient rules out the possibility of influenza (flu) (Belser et al., 2018). Sneezing is a common symptom in patients with allergic rhinitis while facial pain is a primary feature in patients with sinusitis (Nur et al., 2022; Ma et al., 2022). J.T. denies sneezing or facial pain which rules out allergic rhinitis and sinusitis.
Plan
- Diagnostics (labs)
- Perform a rapid strep test to establish whether streptococcus is causing the symptoms
- Perform nasal endoscopy to establish the actual cause of nasal blockage
- Medications
- Continue 400 mg of ibuprofen twice a day for 2 weeks
- Prescribe Afrin, a nasal decongestant to help improve the nasal congestion (DeGeorge et al., 2019).
- Referral
- Referrals are not necessary at this point.
- Patient Education and Health Maintenance
- Educate J.T. to adhere to medication (DeGeorge et al., 2019).
- For health maintenance, J.T. should wear warm clothing and eat lots of fruits and vegetables.
- Follow-Up: J.T. should come back to the clinic after two weeks for evaluation.
References
Belser, J. A., Lash, R. R., Garg, S., Tumpey, T. M., & Maines, T. R. (2018). The eyes have it: influenza virus infection beyond the respiratory tract. The Lancet. Infectious diseases, 18(7), e220–e227. https://doi.org/10.1016/S1473-3099(18)30102-6
DeGeorge, K. C., Ring, D. J., & Dalrymple, S. N. (2019). Treatment of the common cold. American Family Physician, 100(5), 281–289.
Ma, F., Xu, L., & Ai, P. (2022). Treatment and impacts of chronic sinusitis with the confluence of biyuan tongqiao granules and saline nasal irrigation. Journal of Healthcare Engineering, 2022, 2916700. https://doi.org/10.1155/2022/2916700
Nur, H., S. M., Tan, H. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic rhinitis: A clinical and pathophysiological overview. Frontiers in Medicine, 9, 874114. https://doi.org/10.3389/fmed.2022.874114
Pappas D. E. (2018). The common cold. Principles and Practice of Pediatric Infectious Diseases, 199–202.e1. https://doi.org/10.1016/B978-0-323-40181-4.00026-8