Case Study
1
You are seeing a 15-month-old male for a sick office visit.
Subjective data:
CC: fever and fussy
HPI: Mom reports 3-day history of increased fussiness, worsening last night, and fever “burning up.” Tylenol given with some relief last night. Decreased po intake per baseline. Reports +wet diaper this morning.
PMH: No hospitalizations, no surgeries (except circumcision at birth). Hx of ear infection at 6 and 11 months of age. Seen a couple of times at UC and given antibiotic; last UC visit 2 months ago. Last antibiotic given unknown.
FH: Mom with hx of ear infections and PE tubes; dad’s hx unknown
SH: Single mom, working night shift, limited support. Maternal grandmother “helps when she can;” also works 5 days a week. Goes to day care 5 days a week, reports +sick contacts at day care. No other siblings at home. Mom smokes.
ROS:
General: increased napping, decreased playing at times
HEENT: clear rhinorrhea and congestion
Resp: Denies cough
GI: No N/V/D
Skin: no rash
Objective data:
VS: Temp 38.4C, HR – 126, RR – 28
Height: 55th%
Weight: 24 pounds
Length/height ratio: 65th%
NKDA: none
Immunizations: UTD
PE:
Gen appearance: NAD, active in room
HEENT: AF closed; sclera clear, no injection, no exudate; clear rhinorrhea; mouth moist, tonsils pink 1+, no exudate; review image below for TMs
Resp: CTA, no wheezing, no rales, no retractions, no nasal flaring
CV: RRR, no murmur; B femoral pulse equal and strong
GI: soft, ND, NT
Skin: pink, no rash
Discuss your differential diagnosis based on the history and exam.
What is your diagnosis? Defend your answer. Include TM/PE exam findings.
Discuss your plan of care, including pharmacologic, non-pharmacologic, diagnostic testing, referrals, and education. Provide evidence to support clinical decision making. Be sure to cite references.
2
Five days later, a nurse communicates to you that the mom of this patient called with concerns regarding a new rash. You decide to bring the patient back in for a sick office visit.
Subjective data:
CC: Rash
HPI: Mom reports new onset of rash last night. Mom did not give antibiotic last night or this morning. Mom reports rash comes and goes and some scratching of rash noted.
ROS:
General: drinking “normal;” 4–5 sippy cups a day and playing
HEENT: clear rhinorrhea
Resp: Denies cough
GI: No N/V/D
Skin: rash “comes and goes,” scratching at leg
Objective data:
VS: Temp 37.6.4C, HR – 112, RR – 24
Height: 55th%
Weight: 24 pounds
Length/height ratio: 65th%
PE:
Gen appearance: NAD, active in room
HEENT: AF closed; sclera clear, no injection, no exudate; clear rhinorrhea; mouth moist, tonsils pink 1+, no exudate; review image below for TMs
Resp: CTA, no wheezing, no rales, no retractions, no nasal flaring
CV: RRR, no murmur; B femoral pulse equal and strong
GI: soft, ND, NT
Skin: review image below for rash
Discuss your differential diagnosis based on the history and exam.
What is your diagnosis? Defend your answer. Include TM/PE and skin exam findings.
Discuss your plan of care, including pharmacologic, non-pharmacologic, diagnostic testing, referrals, and education. Provide evidence to support clinical decision making. Be sure to cite references.
3
You arrive at the clinic and review your schedule for the day and see the 15-month-old back on your schedule. You talk with the triage nurse, and she reports that mom called right before the end of the day yesterday and was concerned regarding fever and cough. This patient was seen 2 weeks ago.
Subjective data:
CC: fever, fussy, and cough
HPI: Mom reports 2-day history of increased fussiness, fever, and cough. Cough worse at night and sounds “wheezy.” Tylenol given last night. Decreased po intake per baseline. Reports +wet diaper this morning.
PMH: No hospitalizations, no surgeries (except circumcision at birth). Hx of ear infection at 6 and 11 months of age. Seen a couple of times at UC and given antibiotic, last UC visit 2 months ago.
FH: Mom with hx of ear infections and PE tubes; dad’s hx unknown
SH: Single mom, working night shift, limited support. Maternal grandmother “helps when she can;” also works 5 days a week. Goes to day care 5 days a week, reports +sick contacts at day care. No other siblings at home. Mom smokes.
ROS:
General: increased napping, decreased playing at times
HEENT: clear rhinorrhea and congestion
Resp: Denies cough
GI: No N/V/D
Skin: no rash
Objective data:
VS: Temp 38.8 C, HR – 132, RR – 30
Height: 55th%
Weight: 23.5 pounds
Length/height ratio: 65th%
NKDA:
PE:
Gen appearance: clinging to mom
HEENT: AF closed; sclera clear, no injection, no exudate; clear rhinorrhea; mouth moist, tonsils pink 1+, no exudate; review image below for TMs
Resp: + wheezing throughout lung fields, no rales, no retractions, no nasal flaring
CV: RRR, no murmur; B femoral pulse equal and strong
GI: soft, ND, NT
Skin: pink, no rash
Discuss your differential diagnosis based on the history and exam.
What is your diagnosis? Defend your answer. Include TM/PE and skin resp. exam findings
Discuss your plan of care, including pharmacologic, non-pharmacologic, diagnostic testing, referrals, and education. Provide evidence to support clinical decision making. Be sure to cite references.
The mom requests cough medication. Describe your response to the mom based on evidence and based on the mom’s low health literacy.
Mom asks about ways to prevent ear infections. Describe your response to the mom, including exposure to second hand smoke.
Identify Erikson and Piaget’s developmental stage of your patient.
Describe your approach to your patient based on that knowledge. Give specific
examples.
