PEDS 602 Week 3: Sick Child Clinical Case Presentation – Chamberlain College of Nursing | PEDS602 Week 3: Sick Child Clinical Case Presentation

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PEDS 602 Week 3: Sick Child Clinical Case Presentation – Chamberlain College of Nursing Week 3: Sick Child Clinical Case Presentation Purpose The purpose of this assignment is for learners to... : • Have the opportunity to integrate knowledge and skills learned throughout all core courses in the FNP track and previous clinical courses. • Demonstrate an advancing understanding of the care of women and children. • Demonstrate the ability to analyze previous patients seen in the clinical setting be able to perform an evidenced-based review of their case, diagnosis, and plan, while guiding and taking feedback from peers regarding the case • Demonstrate professional communication and leadership, while advancing the education of peers. Course Outcomes 1. Integrate current evidence based clinical practice guidelines in the care of childbearing and childrearing families. 2. Appropriately apply anticipatory guidance and health promotion in the care of childbearing and childrearing families. 3. Assess growth and developmental milestones in the care of childbearing and childrearing families. 4. Construct an evidence based reproductive health management plan. 5. Identify and address healthcare needs of marginalized childbearing and childrearing families Requirements For Week 3 of the course you will be presenting your own case from clinical. The case should be clear, organized, and meet the following guidelines: Initial Case Presentation: Present only the subjective and objective data only on the patient organized as you would organize them in a SOAP (CC, HPI (no OLDCART for HPI); ROS, PE findings, and any lab or diagnostic findings for your patient. **Do not put the diagnosis or plan in initial post. No Assessment/Plan in the initial post. No citations or references are required for your initial post, you will post references in your summary post.  WEEK 3: The case should be pediatric (a patient age 17 years or younger). WEEK 3 specific guidelines: The case must not be something overly simple. The list of things that should not be covered include sore throat, URI, UTI, ear infection, or contact dermatitis (poison ivy). You need to present a case that intrigued you or presents new content in a different light. *One of the above diagnosis can be presented if the findings were unusual and you clear such case with your course faculty prior to posting (at least 2 days before posting). In the pediatric case you must also include in the objective data growth chart percentiles for height, weight, and BMI, and tanner staging. A patient you saw both for initial complaint and follow-up would be ideal, but not required. Leading the Discussion: Post your subjective, objective, and diagnostic data for your patient by Wednesday at 11:59 PM MT. Interactive Dialogue: As a student you will also be required to respond to at least two (2) other students initial case presentation. In your responses, you must include the following: Your top three (3) differentials based on the information provided and why (rationale based on presentation findings), the primary diagnosis you are leaning toward, how you would treat that diagnosis. Use references to support your response. *DEADLINE - YOUR RESPONSES TO 2 STUDENTS ARE DUE BY FRIDAY AT 11:59 p.m. (MT). **If all students have a response, then choose the student with the least responses to their posting. Clinical Case Presentation Summary Criteria: By Sunday 11:59 p.m. MT, post a summary reply to your initial post and respond to any faculty questions to your initial posting or question(s) posed to the general class. Use references to support all of your responses. Criteria for Summary Post should include all of the following required elements: Summary post written in paragraph(s) type format (No SOAP note for Summary Post); discuss primary and any applicable secondary diagnoses along with treatment plan for each diagnosis. Scholarly and evidence based in-text citation support for all of the listed diagnoses; Scholarly and evidence based in-text citation for each treatment plan. Differential diagnoses are eliminated. Summarize your peer's posts to your presentation. *Remember not to use any patient identifiers in your posting (this would be full names or disclosure of clinic name, preceptor name, et cetera). Please include age, gender, and race. **To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric. Search entries or author Filter replies by unreadUnread     Collapse replies Expand replies  Subscribed • Collapse SubdiscussionRachel Cox Rachel Cox Mar 16, 2020Mar 16 at 4:33pm Manage Discussion Entry Patient Information: 7-year old, African American, Female Subjective. CC : Scalp itchy and painful with dry skin and significant hair loss HPI: Mother stated the condition has been present for 2 months and has gradually gotten worse. Current Medications: no current medications Allergies: Sulfa drugs PMHx: Up to date on vaccines, no surgical history, no past major illnesses.

Soc Hx: currently in 2nd grade in a public school, has frequent sleepovers with friends, on a soccer team, enjoys reading. No one in house smokes, wears her seatbelt. Fam Hx: lives with her mom, brother, and two sisters. ROS: CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue. HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN:  Scalp is dry with itchy, painful, scaly patches. Significant hair loss present on head CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:  No shortness of breath, cough or sputum. GASTROINTESTINAL:  No nausea, vomiting or diarrhea. No abdominal pain. GENITOURINARY:  No urinary issues. NEUROLOGICAL:  No headache, dizziness, syncope, numbness or tingling in the extremities. No change in bowel or bladder habits MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness. HEMATOLOGIC:  No anemia, bleeding or bruising. LYMPHATICS:  Enlarged occipital, postauricular, submandibular, and posterior cervical nodes.  No history of splenectomy. PSYCHIATRIC:  No history of depression or anxiety. ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES:  No history of asthma, hives, or eczema. Objective. Physical exam: HEENT:  Eyes:  PERRLA, sclera is white and clear, conjunctiva pink and moist Ears, Nose, Throat:  No drainage present in bilateral ears, no swelling, redness, drainage, effusion or cerumen present bilaterally. No hearing loss. No sneezing, congestion, or drainage present in nose.  Posterior pharynx is pink & there is no post nasal drainage, tonsils are 2 +. SKIN:  Scalp is dry with itchy, painful, scaly patches. Significant hair loss present on head CARDIOVASCULAR:  S1, and S2 auscultated, regular rate RESPIRATORY:  Lungs clear to auscultation in all lobes anterior and posterior GASTROINTESTINAL:  Bowel sounds present in all four quadrants. No abdominal pain or tenderness upon palpation. MUSCULOSKELETAL:  Full ROM present in upper and lower extremities LYMPHATICS:  Enlarged and tender bilateral occipital, postauricular, submandibular, and posterior cervical nodes.   height: 3’10” weight: 55 lbs BMI: 18.3 Growth chart: 66% for weight, 13.5% for height Tanner staging: Stage 1 Diagnostic results: No diagnostic tests run o Collapse SubdiscussionJacqueline Costello Jacqueline Costello Mar 16, 2020Mar 16 at 5:12pm Manage Discussion Entry Hi Rachel,   Thanks for starting us off this week and for the interesting case. Since you mentioned Tanner staging, is it considered normal for a 7 yr old to have their menses? Why or why not?  At what age would it be considered precious puberty?   Looking forward     Dr. C  Rachel Cox Rachel Cox Mar 17, 2020Mar 17 at 5:11pm Manage Discussion Entry Dr. C., Thank you for your response and questions It is not considered normal for a 7-year-old to have their menses. Khan (2019) states the normal age rate for the onset of puberty in females is between 8 and 13 years old. Precocious puberty is defined as the onset of puberty before girls are 8 years old and boys are 9 years old. True precocious puberty is accompanied by growth acceleration, breast development, and menarche in females. None of these symptoms were reported or present by the 7-year-old patient in the case study. This 7-year-old was not pubescent.     References Khan., L. (2019). Puberty: Onset and progression. Pediatric Annals, 48(4):141-5. o Tara Hudak Tara Hudak Mar 19, 2020Mar 19 at 1:47pm Manage Discussion Entry Hi Rachel, interesting case study. Based off the patient information that you presented I would choose the differential diagnoses of, seborrheic dermatitis, scalp psoriasis and atopic dermatitis.   Seborrheic dermatitis: Seborrheic dermatitis is characterized by pruritic, erythematous patches with easily detachable, greasy large scales (Chernoff, Lin, & Cohen, 2014).  It can appear in various anatomical locations and tends to occur in areas that contain numerous sebaceous glands, such as the scalp, face, upper chest, and back (Chernoff, Lin, & Cohen, 2014).  Seborrheic dermatitis of the scalp commonly presents as dandruff, a milder eruption, characterized by smaller dry, flaking scales (Chernoff, Lin, & Cohen, 2014).   Subjective:  Patient presents with itchy and painful scalp with dry skin  No history of asthma, hives, or eczema  Plays sports  Objective:  Scalp is dry with itchy, painful, scaly patches. Significant hair loss present on head  Scalp Psoriasis: Plaques typically form on the scalp and along the hair margin. This is the commonest involved area and many patients discover they have psoriasis because of a dandruff-like desquamation of the scalp (Reid & Griffiths, 2020).  Scalp psoriasis doesn’t assume a follicular distribution and psoriasis involving hair follicles of the trunk and limbs has a follicular pattern with children being more frequently affected (Reid & Griffiths, 2020).  Subjective:  Aged 7  Scalp is dry with itchy, painful, scaly patches.  No history of asthma, hives, or eczema  Objective:  Scalp is dry with itchy, painful, scaly patches  Atopic Dermatitis: Atopic dermatitis is a common, chronic inflammatory disease with onset occurring most often in early childhood (Salvador, Romero-Pérez, & Encabo-Durán, 2017). Many patients have severe disease that is very difficult to manage. They usually have diffused, symmetrical, and flexural dermatitis, primarily with eczema of the face, but also with uneven involvement of the trunk and limbs (Salvador, Romero-Pérez, & Encabo-Durán, 2017).      Subjective:  Age 7  No history of asthma, hives, or eczema  2-month worsening onset  Objective:  Scalp is dry with itchy, painful  Significant hair loss present on head    Primary Diagnosis: The diagnosis I would learn to for this patient is seborrheic dermatitis. It is a chronic inflammatory dermatologic condition that usually appears on areas of the body with a large density of sebaceous glands, such as the scalp, face, chest, back, axilla, and groin (Chernoff, Lin, & Cohen, 2014).  This child plays soccer and may frequently be warm and sweaty.  In children and adults, seborrheic dermatitis typically presents as flaky, greasy, erythematous patches on the scalp, nasolabial folds, ears, eyebrows, anterior chest, or upper back (Chernoff, Lin, & Cohen, 2014).  If the diagnosis is uncertain, a biopsy demonstrating parakeratosis in the epidermis, plugged follicular ostia, and spongiosis can confirm the presence of seborrheic dermatitis (Chernoff, Lin, & Cohen, 2014).  Treatment of seborrheic dermatitis in adolescents is identical to that in adults with the primary goal to lessen the visible signs of the condition and to reduce pruritus and erythema (Chernoff, Lin, & Cohen, 2014).  For mild seborrheic dermatitis of the scalp, over-the-counter dandruff shampoos containing selenium sulfide, zinc pyrithione, or coal tar can control symptoms at a fraction of the cost of other treatments (Chernoff, Lin, & Cohen, 2014).  Seborrheic dermatitis is a chronic condition and for that reason ongoing maintenance therapy is often necessary (Chernoff, Lin, & Cohen, 2014).     Topical Anitfungals that may also be used:  Ciclopirox 1% shampoo  Ketoconazole 2% shampoo  Clobetasol 0.05% shampoo (Clobex), alternating with ketoconazole 2% shampoo   References Chernoff, K., Lin, R., & Cohen, S. R. (2014). Seborrheic Dermatitis. Atopic Dermatitis and Eczematous Disorders, 275–287. doi: 10.1201/b16138-18 Reid, C., & Griffiths, C. (2020). Psoriasis and Treatment: Past, Present and Future Aspects. Acta Dermato Venereologica, 0. doi: 10.2340/00015555-3386 Salvador, J. S., Romero-Pérez, D., & Encabo-Durán, B. (2017). Atopic Dermatitis in Adults: A Diagnostic Challenge. Journal of Investigational Allergology and Clinical Immunology, 27(2), 78–88. doi: 10.18176/jiaci.0138 o Kirsten Dunning Kirsten Dunning Mar 19, 2020Mar 19 at 2:05pm Manage Discussion Entry Rachel, You have provided thorough information on this patient. my 3 differential diagnoses include psoriasis, seborrheic dermatitis, and eczema.  Differential Diagnosis Psoriasis is characterized by thick, crusty plaques on the scalp that may itch (National Psoriasis Foundation, 2019). Hair loss may occur due to excessive itching, along with increased thickening of the skin. Although unsure of what causes flare-ups, some triggers include stress, a bacterial infection, excess sweat, dry weather, and sunburns (American Academy of Dermatology Association, 2020). Seborrheic dermatitis is lesions occurring in areas where the skin is full of sebaceous glands, especially on the scalp and face. Normally, this diagnosis is asymptomatic, however, pruritis can be present. A mild form of seborrheic dermatitis can cause the shedding of small light-colored flakes of skin, noted to be dandruff (Tucker and Masood, 2019).  Eczema is the most common form of atopic dermatitis.  People with the disease tend to have dry, itchy skin that is prone to infection and normally affects children but can be seen in adults (Nemeth and Evans, 2019). In the beginning, the patient will itch the skin and then a rash will form. When the person continues to scratch the area, the skin starts to thicken. As patients get older, the most likely areas for this disease is in the crooks of the elbows and behind the knees (Nemeth and Evans, 2019).    Primary diagnosis: Eczema   Treatment: The most important treatment for eczema is keeping the area hydrated. Applying unscented moisturizers to the skin daily can help decrease the chance for a flare-up. Hot water should be avoided during bathing/showering. Instead, warm water should be used.  Next, topical corticosteroids are the treatment of choice to help with the itching and inflammation of atopic dermatitis (eczema).  A low potency steroid should be used as the affected area is on the scalp. Hydrocortisone acetate 1% should be applied once to twice daily for flare-ups (Wong, Tsuyuki [...], and  Drucker, 2017).    - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - phrine (Smith et al., 2018). The need for oxygen should be adequately assessed, and if indicated, oxygen should be provided. Differential Diagnoses Bacterial Tracheitis Rationale: Bacterial tracheitis in children typically occurs in those below six years (Smith et al., 2018). However, children of any age can be affected. Even though rare in children, the disease is often life-threatening and may be met with an emergency (Casazza et al., 2019). Patients with bacterial tracheitis present with hoarseness, rhinorrhea, nonproductive cough, inspiratory stridor, subglottic erythema, diffuse edema of the tracheal mucosa, barking cough and high fever (Tak et al., 2018). The diagnostic test involves complete blood count, neck radiography, as well as laryngoscopy. To this end, neck radiography often shows irregular tracheal mucosa. Proper diagnosis should follow the history of the onset of disease and a history of previous medical conditions. A history of sudden onset stridor is indicative of bacterial tracheitis. Also, a case of bacterial tracheitis may be suspected if there is a previous tracheostomy, intubation, and antecedent upper respiratory infection (Griffin & Young, 2015). Foreign Body Aspiration Rationale: Foreign body aspiration presents in the form of chock when a foreign body enters the child's airways. Children of up to 18 months are commonly affected, but those up to 3 years of age are not resistant (Parameswaran & Biswal, 2018). This condition occurs as a life-threating condition and presents with chronic cough, fever, chest pain, dyspnea, and foul-smelling sputum (Cramer et al., 2018). A proper diagnosis requires lateral soft tissue and the posterior-anterior view of the neck. A chest radiograph may be taken to appreciate lower respiratory airway obstruction. Plain radiographs often show radiolucent foreign bodies. The examiner may also check on the foul-smelling sputum. This condition may be considered a differential diagnosis because of the frequent coughs and the nature of reporting.  References Casazza, G., Graham, M. E., Nelson, D., Chaulk, D., Sandweiss, D., & Meier, J. (2019). Pediatric bacterial tracheitis—a variable entity: Case series with literature review. Otolaryngology-Head and Neck Surgery, 160(3), 546-549. doi: 10.1177/0194599818808774 Cramer, N., Jabbour, N., Tavarez, M. M., & Taylor, R. S. (2018). Foreign body aspiration. doi: 10.1097/01.JAA.0000558368.93609.08 Griffin, E. S., & Young, T. M. (2015). Bacterial tracheitis in a 9-month-old child. Journal of Emergency Nursing, 41(2), 109-112. doi: 10.1016/j.jen.2015.01.002 Lin, S. C., Lin, H. W., & Chiang, B. L. (2017). Association of croup with asthma in children: A cohort study. Medicine, 96(35) , e7667. doi: 10.1097/MD.0000000000007667 Matsuura, H., & Shimanouchi, Y. (2017). Steeple sign and acute laryngotracheobronchitis. QJM: An International Journal of Medicine, 110(11), 767-767. doi: 10.1093/qjmed/hcx156 Parameswaran, N., Das, S., & Biswal, N. (2018). Respiratory morbidity following foreign body aspiration among south indian children: A descriptive study. Cureus, 10(11), e3629. doi: 10.7759/cureus.3629 Risteska–Nejashmikj, V., Stojkovska, S., & Stavrikj, K. (2018). Dyspnea in children as a symptom of acute respiratory tract infections and antibiotic prescribing. Open access Macedonian journal of medical sciences, 6(3), 578-581. doi: 10.3889/oamjms.2018.146 Smith, D. K., McDermott, A. J., & Sullivan, J. F. (2018). Croup: Diagnosis and management. American family physician, 97(9), 575-580. Tak, R., Semmekrot, B., Warris, A., Yntema, J. B., Stelma, F., & Neeleman, C. (2016). Bacterial tracheitis and septic shock. The Pediatric infectious disease journal, 35(2), 226-227. doi: 10.1097/INF.0000000000000981    Elena Hamant Elena Hamant Mar 22, 2020Mar 22 at 8:26pm Manage Discussion Entry In my initial post I introduced MH a three-year-old girl with respiratory distress. She displayed several cardinal signs for laryngotracheitis otherwise known as croup including symptoms worse at night with abrupt onset, barking cough and steeple sign on chest radiographs as shown below.   Yoandra explained that symptoms are diagnostic without any testing. The above listed signs and symptoms the patient displayed are obtained on history and review of systems. Yoandra included bacterial tracheitis in her differential list which has several similar signs and symptoms as laryngotracheitis. They can be differentiated with xray as bacterial tracheitis shows irregular tracheal mucosa rather than the steeple sign of croup. Rachel Cox and Rachel Rey both included information about laryngotracheitis that the symptoms are apparent before the symptoms of an illness (Johnson, 2016). This means the child goes to bed normal and wakes up in acute respiratory distress. This is unlike many other viral illnesses so is often a clue to providers that the cause is likely laryngotracheitis. Rachel included epiglottitis to her differential list. This and laryngotracheitis can be differentiated by viewing the xray which had the steeple sign. Epiglottitis would present with xray findings of inflamed epiglottis. In the case of this patient she did present with some drooling which is a cardinal sign and the reason for needing to rule out epiglottitis with an xray. Radiographs were required for accurate diagnosis since epiglottitis and bacterial tracheitis are both life threatening conditions. However, croup patients usually do not present so acutely and do not need xrays (Smith et al., 2018). Treatment for this patient included oral prednisolone which Yoandra described in her response post as being effective for croup. The dosing was 1.0mg/kg PO daily for three days (Smith et al., 2018). Oxygen and racemic epinephrine were not required since it was a mild case. The patient and family were advised to stay for monitoring until the cough subsided and she was sent home.   References: Johnson, D. W. (2016). Croup. American Family Physician, 94(6): 476-478 Smith, D. K., McDermott, A. J., & Sullivan, J. F. (2018). Croup: Diagnosis and management. American family physician, 97(9), 575-580.   • Collapse SubdiscussionRachel Rey Rachel Rey Mar 17, 2020Mar 17 at 6:52pm Manage Discussion Entry Week 3 Sick Child Case Study Patient Information: o Initials: M.R. o Age: 10 o Gender: Female (Caucasian) S: Subjective o Pain (1-10): Zero o Chief Complaint (CC): New patient to establish care / Skin concerns o HPI: MR is a 10-year-old female. Source of patient information is the father and the patient. Allergy list reviewed. Problem list reviewed. Medication reconciliation performed. Allergies o No known Allergies to Food, Medication or Environmental factors Current Medications o Methylphenidate HCl 10 mg    Daily      taken for 1 year for ADHD o Medications reviewed including OTC meds. Past Medical History (PMHx) – o Source of patient history was the father. No pulmonary symptoms as a newborn, no previous hospitalizations, not taking antibiotics recently, newborn hearing screen was normal. o Prenatal: No pregnancy history or infections during pregnancy. Deliver was in a hospital with breech presentation by cesarean section. Gestational age was 40 weeks, Gravida 2, Para 2. Prenatal maternal history normal for prescription and OTC drug use during pregnancy. No history of prenatal maternal STDs, not smoking and no narcotics during pregnancy. No alcohol use or IV drug use during pregnancy. No diabetes and no eclampsia during pregnancy. Prenatal care was routine. o Pediatric: no pre-existing maternal hypertension. Mothers antepartum labs were normal, showed PPD-, HepB-, HIV-, sickle cell – and negative for Strep group B. No ABO incompatibility during pregnancy and no Rh. Mothers age at delivery was 27 years. Newborn did not remain hospitalized after mother was discharges. Neonatal Jaundice. No difficulty feeding. Weight was 7.13 lbs at birth, and 7.3lbs at time of discharge from nursery. No oxygen was needed at birth, no phototherapy, no admission to NICU and no surgeries. o Immunizations from birth through age 10 are up to date. She was evaluated 1 year ago and after prolonged monitoring started on Ritalin due to her grades suffering and inability to focus during times of schoolwork. Grades have now improved, and she is only using the medication on school days. Social History (Soc Hx) - o No drug use during pregnancy. Child lives at home with both parents in a private residence. There is a household pet, a dog. She is not currently enrolled in any extracurricular activities as they just moved from Texas. She rides in the back seat of the car, wears her seatbelt and enjoys music and playing outside. She has one sibling, a sister, 2.5 years younger. The home is in a rural, gated community, and has functioning water, electric, smoke detectors and appliances. Family History (Fam Hx) - o Mother is alive and healthy. Father is alive and healthy. Sibling is alive and health, no signs of ADHD at this time. Paternal grandparent has heart disease, hypertension and asthma. Maternal grandparent negative family history including depression. Review of Systems (ROS): (Pertinent positives only) CONSTITUTIONAL: AAOx3, NAD SKIN: Smooth, pearly papule/lesions on right knee & left posterior thigh/hamstring with itching PSYCHIATRIC: Trouble concentrating (on medication) GYN: Adrenarche & asymmetrical breast budding noted O: Objective o BP: 102/70 mmHg o HR: 103 bpm (Regular) o Temp: 98.6 (Tympanic) o Respiratory rate: 18 per min o Height: 54.5 inches      o Growth chart percentile: 51.2% (on target) o Weight: 09kg                               o Growth chart percentile: 55.6% (on target) o BMI: 17.8kg/m2    o BMI Percentile: 64%           o BSA: 1.15m2 o Tanner Stage: Two. Breast budding, asymmetrical & adrenarche. o No Labs or diagnostic studies were ordered at this time Photo of condition (similar appearance) courtesy of Google (not actual patient photo) I could not get the growth charts to attach within the content, so I have attached them as a word file.  week 3 - case study - SOAP_Subj & Obj Only - CHARTS.docx o Collapse SubdiscussionJacqueline Costello Jacqueline Costello Mar 18, 2020Mar 18 at 5:04pm Manage Discussion Entry Hi Rachel, Thanks for sharing.    I see your patient was afebrile.  Speaking about fevers. There is something known as "fever phobia" in the pediatric community.  Can you tell us what that term means, please?  I tell parents "fever is our friend", why do you think I tell them this?    Looking forward   Dr. C    Rachel Rey Rachel Rey Mar 19, 2020Mar 19 at 6:24am Manage Discussion Entry Dr. Costello, Fever phobia is something that gained popularity in the early 1980s that was intended to explain amplified and reactionary fears of fever in children conveyed by parents and caregivers (Purssell & Collin, 2016). Although the concerns were demonstrated as unfounded, the fear of a child having a fever remains and is a primary reason for ER visits among children (Elkon-Tamir, Rimon, Scolnik, & Glatstein, 2017). Your instruction to parents that “fever is our friend” is most likely the best way to help them understand that fever is a reliable indicator of infection being present (Gunduz, Usak, Koksal, & Canbal, 2016). In my learning and experiences, the degree of infection is what is key with fever. If it is a mild fever in an otherwise healthy child, then sometimes letting a fever “run its course” is best to help strengthen the child defense against organisms. However, in an immunocompromised child or child with other serious health conditions, fever can be dangerous and should be evaluated in terms of the individual. As a parent, I understand that “fear” of what complications can ensue with a fever, but as a practitioner I have to help them know when a fever is acceptable and when it is truly a cause for concern.   Source: Elkon-Tamir, E., Rimon, A., Scolnik, D., & Glatstein, M. (2017). Fever phobia as a reason for pediatric emergency department visits: Does the primary care physician make a difference? Rambam Maimonides medical journal, 8(1), e0007. https://doi.org/10.5041/RMMJ.10282 Gunduz, S., Usak, E., Koksal, T., & Canbal, M. (2016). Why fever phobia is still common? Iranian Red Crescent medical journal, 18(8), e23827. https://doi.org/10.5812/ircmj.23827 Purssell, E., & Collin, J. (2016). Fever phobia: The impact of time and mortality – A systematic review and meta-analysis. International Journal of Nursing Studies, 56, 81-89. doi: 10.1016/j.ijnurstu.2015.11.001 o Rachel Rey Rachel Rey Mar 21, 2020Mar 21 at 9:41am Manage Discussion Entry Week 3 Sick Child Case Study - Summary Patient Information:  Initials: M.R.  Age: 10  Gender: Female (Caucasian) Assessment Primary Diagnosis is Molluscum Contagiosum, B08.1 (Epocrates, 2020). Pertinent finding included pearly papule, and pruritus. One differential diagnosis could have been Viral Warts, unspecified, B07.9 (Epocrates, 2020). Due to the appearance of the lesions, and the growth over weeks to months, as well as the round, raised papule, grayish-white color appearance. Another differential to consider could have been varicella [Chicken Pox], without complication, B01.9 (Epocrates, 2020). The appearance of a vesicular rash, pruritus, HA, Fatigue, sore throat, tachycardia could have all been symptoms associated to make this diagnosis. Treatment Plan Although highly contagious, Molluscum contagiosum is a self-limiting infection that typically resolves without intervention (Allmon, Deane & Martin, 2015). First line treatment is observation, then curettage biopsy. Topical anesthetics may be used and if treatment by curettage becomes necessary, and th patient will be referred to dermatology. In this case, no testing was to be done at this time. Pharmacologically, she should continue her previous medications (Adderall). No treatment is needed at this time. The typical resolution of Molluscum Contagiosum happens over a period of months in healthy children and adults (van der Wouden et al., 2017). The infection is often treated due to aesthetic reasons, to avoid societal embarrassment or to prevent spreading the infection (van der Wouden et al., 2017). Although viral warts were ruled out due to advanced assessment, there would have been no medical intervention if it had been the diagnosis. Most viral warts spontaneously disappear in about 2/3 of children within a few years without any therapeutic interventions being necessary (Up to date, 2020). If Varicella (chickenpox) would have been the diagnosis, the best form of prevention is vaccination (CDC, 2018). There are at home remedies for the relief of symptoms of chicken pox once an infection has been confirmed. Calamine lotion, cool baths with baking soda in the water, a paste made from uncooked oatmeal can help with the symptoms of itching (CDC, 2018), Education to avoid scratching to prevent spreading the virus and reduce the potential for bacterial skin infection from occurring (CDC, 2018). Referral/Consults No referrals were made for this condition at this time. Due to the child having ADHD, a referral to Behavioral Health (Pediatric) was made for ADHD medication management. While medical practitioners can adequately dose medication for ADHD, evaluation of rating scales, duration of use for specific stimulant class of medications, assessing baseline symptoms and inclusion of behavioral interventions is best suited with specialists for children and adolescents (Brown, Samuel, & Patel, 2018). Education: Education specific to the skin condition included to avoid scratching & cover when playing to avoid the spread onto other areas or other people. Also avoid sharing towels. Common precautions are recommended to prevent the spread such as avoid scratching or rubbing the lesions, and do not share towels, tubs, or bathing items (Robinson, Townsend & Jahnke, 2020). Additionally, education that was discussed during this visit included age appropriate recommendations for reinforcement of good behavior & redirect when necessary, especially as related to her ADHD symptoms (Hollier, 2018). Proper diet was also discussed, including the elimination of sugar, dyes & some additives which have been shown to negatively impact ADHD symptoms (Hollier, 2018). Physical activity was also discussed such as moderate-to-intense aerobic exercise, which has been demonstrated to have encouraging influences for children and adolescents with ADHD (Ng, Ho, Chan, Yong & Yeo, 2017). Follow-Up: The patient is young and healthy. Molluscum Contagiosum typically resolves on its own, so specified treatment is observation (Robinson, Townsend & Jahnke, 2020). Follow up will occur during her annual wellness exams. However, if the papules begin to spread further, worsen or if the child develops pain, a fever, swelling or redness with signs of infection at the site return to clinic or local ER (if needed) as soon as possible. There were no peer posts to my case to include in this summary.   References: Allmon, A., Deane, K., & Martin, K. (2015). Common skin rashes in children. University of Missouri–Columbia School of Medicine, Columbia, Missouri; 92(3):211-216. Retrieved from https://www.aafp.org Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02 Centers for Disease Control and Prevention (CDC). (2018). Chickenpox (Varicella): Prevention and treatment. U.S. Department of Health & Human Services (Links to an external site.) . Retrieved from https://www.cdc.gov Epocrates. (2019). Molluscum Contagiosum. Epocrates for Android. Retrieved from www.epocrates.com/mobile/samsunggalaxystore Epocrates. (2019). Varicella [chickepox]. Epocrates for Android. Retrieved from www.epocrates.com/mobile/samsunggalaxystore Epocrates. (2019). Viral Warts. Epocrates for Android. Retrieved from www.epocrates.com/mobile/samsunggalaxystore Hollier, Amelie. (2018). Clinical Practice Guidelines in Primary Care (3rd ed., pp. 605-606). Advanced Practice Education Associates, Inc. Ng, Q., Ho, C., Chan, H., Yong, B., & Yeo, W. (2017). Managing childhood and adolescent attention-deficit/hyperactivity disorder (ADHD) with exercise: A systematic review. Complementary Therapies in Medicine, 34, 123-128. doi: 10.1016/j.ctim.2017.08.018 Robinson, G., Townsend, S., & Jahnke, M. (2020). Molluscum contagiosum: Review and update on clinical presentation, diagnosis, risk, prevention, and treatment. Current Dermatology Reports. doi: 10.1007/s13671-020-00289-z Up to date. (2020). Viral Warts. Up to Date for Android. Retrieved from www.uptodate.com van der Wouden, J., van der Sande, R., Kruithof, E., Sollie, A., van Suijlekom-Smit, L., & Koning, S. (2017). Interventions for cutaneous molluscum contagiosum. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.cd004767.pub4 • - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - second part is a separate diagnosis of anemia. It is possible that the findings of anemia on the CBC is an incidental finding and not related to the joint pain but does explain the fatigue. The treatment plan for this is to investigate the source of anemia by assessing for bleeding, lab work as discussed above and increasing dietary intake of iron, b-12 and folic acid while trying to determine cause and adding specific treatment based on type of anemia (Papakakis et al., 2020). A final possible diagnosis is juvenile idiopathic arthritis (JIA). This is unlikely to be diagnosed at this time due to the fact that the duration of symptoms has been less than 6 weeks, the pain has been constant without improvement, there is no joint swelling or warmth and while patient has pain with movement there is no decreased ROM (Crayne & Beukelman, 2018). ESR, CRP, ANA, RF and WBC are laboratory markers that may indicate a chronic inflammatory disease, such as JIA, and should be ordered in this case but are not diagnostic (Crayne & Beukelman, 2018). Due to the chronic, progressive and debilitating nature of JIA treatment is focused on alleviation of symptoms. The treatment includes NSAID, steroids, DMARDS and biological DMARDS (Crayne & Beukelman, 2018). I appreciate the input from Margeaux. When I was looking through symptoms, I did consider SLE but did not pursue it due to the lack of rash in this case. I did not consider lyme disease either, however the hallmark symptoms of a bullseye rash is missing and while this does not completely exclude the diagnosis, it does make it less likely. This case was difficult for me as I fell prey to confirmation bias. I thought about SCD as soon as I read this case and had to fight to find anything to support a different diagnosis. I can see how first impressions can lead to following the wrong path and potential misdiagnosis. Vanessa Abzug, M. J., Deterding, R. R., Hay, W. W., & Levin, M. J. (2014). Current diagnosis & treatment pediatrics. Mcgraw-Hill Education Llc. Balan, S. (2016). Approach to Joint Pain in Children. The Indian Journal of Pediatrics, 83(2), 135–139. https://doi.org/10.1007/s12098-015-2016-8 CDC. (2017, July 27). Sickle Cell Disease Clinical Guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/sicklecell/recommendations.html Crayne, C. B., & Beukelman, T. (2018). Juvenile Idiopathic Arthritis. Pediatric Clinics of North America, 65(4), 657–674. https://doi.org/10.1016/j.pcl.2018.03.005 Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. (2014). Pediatrics, 134(6), e1775–e1775. https://doi.org/10.1542/peds.2014-2986 Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. (2014). Pediatrics, 134(6), e1775–e1775. https://doi.org/10.1542/peds.2014-2986 (Links to an external site.) Ibuprofen. (2020). Epocrates Rx. (Version 20.2) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile (Links to an external site.) Lortab. (2020). Epocrates Rx. (Version 20.2) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile (Links to an external site.) Papadakis, M. A., Mcphee, S. J., & Rabow, M. W. (2020). Current medical diagnosis & treatment 2020. Mcgraw-Hill Education. Pelizzo, G., Guazzotti, M., Klersy, C., Nakib, G., Costanzo, F., Andreatta, E., Bassotti, G., & Calcaterra, V. (2018). Spleen size evaluation in children: Time to define splenomegaly for pediatric surgeons and pediatricians. PLOS ONE, 13(8), e0202741. https://doi.org/10.1371/journal.pone.0202741 Ware, R. E., de Montalembert, M., Tshilolo, L., & Abboud, M. R. (2017). Sickle cell disease. The Lancet, 390(10091), 311–323. https://doi.org/10.1016/s0140-6736(17)30193-9 • Collapse SubdiscussionShamma Chery Shamma Chery Mar 17, 2020Mar 17 at 1:04pm Manage Discussion Entry Hello everyone!  CASE STUDY Patient Information: CN 17 years old, Male S. CC Night sweats, sore throat, swelling left groin, dependent rubor HPI: 17 year old male presents to the clinic, accompanied with mother, with complaints of headache, sore throat, post nasal drip, cough, night sweats, swollen lymph nodes and sore gums. Patient states symptoms began one week ago and has not taken any medications for the symptoms. Describes headaches as "head pressure" and only in the mornings and located around the front of his head. Denies any new allergy triggers. Does have seasonal allergies Current Medications:  No current medications Allergies: NKDA Season Allergies PMHx: None Social Hx: Lives with parents and sibling. Denies tobacco, ETOH, illicit drug use, wears seatbelt in vehicle Fam Hx: Mother and father are both healthy and living. Siblings both healthy and alive as well. PGP: died from unknown causes, PGM: Stroke at age 62. MGM: 66, COPD. No MGP in the picture. ROS: CONSTITUTIONAL:  No fever, chills, weakness or fatigue. No weight change, generally healthy, no change in activity level. Not exposed to similar sick contacts HEENT:  Head: facial pressure, pressure Headaches, no injury, no bruising. Eyes: Normal vision, no tearing, no pain. Ears: No change in hearing, no bleeding. Nose: No epistaxis, coryza, post nasal drip, green discharge, no foreign body. Mouth: "my gums feel sore on the top", sore throat, No dental difficulties, no gingival bleeding. Neck: No stiffness, no pain, no tenderness, no noted masses. Chest: No dyspnea, no wheezing, no hemoptysis, no cough. CARDIOVASCULAR:  Red legs, No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:  Patient reports shortness of breath mostly while at work. No cough or sputum. MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness. LYMPHATICS:  Swelling left groin. No history of splenectomy. PSYCHIATRIC:  No history of depression or anxiety. No changes in sleep habits. ALLERGIES:  History of eczema as a child and seasonal allergies now. O. Physical exam: Height 6'2", Weight 158 pounds, BMI: 20.3, 53th percentile for his age Vital signs : BP 106/62, T 98.1, P 99, R 18 Sao2 98% on RA General: 17-year-old Caucasian male appears stated age in no apparent distress. Alert, oriented, and cooperative. Able to speak in full sentences and does not appear breathless. Normotensive. HEENT: Normocephalic, no lesions. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Small amount of fluid noted right greater than left. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nose: Maxillary sinuses tender to palpation. Nares patent with thin white exudate noted. Mucosa pink. No deviated septum noted. Throat: Post nasal drip, Erythema noted to posterior pharynx, scant amount of white exudate present to bilateral tonsils right greater than left, tonsils +1, tonsillar lymph nodes tender to palpation bilaterally but no lymphadenopathy noted, no lesions. Neck: supple, no masses, no thyromegaly, no bruits. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored. No rales, no rhonchi, no wheezes. CV: Dependent rubor bilaterally, Heart S1 and S2 noted, RR, no murmurs, no rubs, no gallops. Peripheral pulses equal bilaterally, no peripheral edema Extremities: FROM, no deformities, no edema, no erythema. Pelvic: Enlarged lymph nodes inner groin on left side. o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 18, 2020Mar 18 at 11:55am Manage Discussion Entry Shama- thank you for this post. I post the same question to you how would you place this chief complaint and patient (or parent) direct words using quotation marks?  Shamma Chery Shamma Chery Mar 22, 2020Mar 22 at 12:43pm Manage Discussion Entry CC "My throat is sore. My body and throat, hurts , I have a night sweat and my left groin is hurting " o Collapse SubdiscussionJennifer Benvin Jennifer Benvin Mar 19, 2020Mar 19 at 7:55pm Manage Discussion Entry Shamma, I enjoyed reading about the patient you saw in your clinical settings. Your patient seems very difficult with trying to decide on what is currently wrong. The patient complained of "night sweats, sore throat, swelling left groin, and dependent rubor." The three-differential diagnosis for this patient was based on the signs and symptoms you are presented during the case study. 1) Infectious mononucleosis "Mono." 2) Streptococcal pharyngitis, "Strep Throat." 3) Non-Hodgkin's lymphoma The first differential diagnosis and my main primary diagnosis for this patient is mono, also known as infectious mononucleosis. Mono is defined as the kissing disease often harmless but highly contagious and infection with the Epstein Barr virus (Ebell et al., 2016). Infectious mononucleosis is transmitted via the saliva, which is why it is called the kissing disease (Rostgaard et al., 2019). Mono takes 4-7 days for it to develop and is usually easy to self-treat if caught early enough (Rostgaard et al., 2019). The signs and symptoms are of the following fatigue, fever, swollen glands, headaches, and could even develop into a rash (Rostgaard et al., 2019). The pertinent positives during this case study and for this diagnosis were fever, swollen glands, headaches. The essential treatment is self-treating rest, fluids, and over the counter, a fever-reducing agent such as Tylenol 1-2 tabs/caps by mouth (PO) q 4-6h, Max 10 tabs or caps/ 24h (Saleh et al., 2020) The second differential diagnosis for this patient could be a possibility of streptococcal pharyngitis. Streptococcal pharyngitis is transmitted by direct contact via the mucus or direct contact of another person's open sore (Norton et al., 2018). Streptococcal pharyngitis develops into a sore throat, fever, swollen lymph nodes of the cervical area (Norton et al., 2018). The treatment for streptococcal pharyngitis is to reduce inflammation and use an oral antibiotic such as amoxicillin 50 mg/kg/day q8hr (Norton et al., 2018).  The third differential diagnosis, Non-Hodgkin's lymphoma, is my last possible alternative diagnosis due to the patient's chief complaint of the swollen groin and dependent rubor. Non-Hodgkin's lymphoma is a type of cancer that develops in the lymphatic system that increased the white blood cell count and produced a high number of lymphocytes (Turtle et al., 2016). The signs and symptoms that are experienced with the NHL are, of course, swollen lymph nodes of the neck, armpits, and groin, fever, abdominal, and chest pain (Nguyen et al., 2017). The treatment for NHL may include but not limited to chemotherapy, bone marrow stimulant, steroid, and possibly a stem cell transplant (Nguyen et al., 2017). Reference Bhaskaran, P. N., Puliyel, M., Myers, M., & Abughali, N. (2018). Multiple Pulmonary Nodules in an Immunocompetent Adolescent with Infectious Mononucleosis. Indian pediatrics, 55(2), 161-162. Ebell, M. H., Call, M., Shinholser, J., & Gardner, J. (2016). Does this patient have infectious mononucleosis? the rational clinical examination systematic review. Jama, 315(14), 1502-1509. Norton, L. E., Lee, B. R., Harte, L., Mann, K., Newland, J. G., Grimes, R. A., & Myers, A. L. (2018). Improving guideline-based streptococcal pharyngitis testing: a quality improvement initiative. Pediatrics, 142(1). Rostgaard, K., Balfour Jr, H. H., Jarrett, R., Erikstrup, C., Pedersen, O., Ullum, H., ... & Hjalgrim, H. (2019). Primary Epstein-Barr virus infection with and without infectious mononucleosis. PloS one, 14(12). Nguyen, T., Parker, R., Hawkins, E., Holkova, B., Yazbeck, V., Kolluri, A., ... & Grant, S. (2017). Synergistic interactions between PLK1 and HDAC inhibitors in non-Hodgkin's lymphoma cells occur in vitro and in vivo and proceed through multiple mechanisms. Oncotarget, 8(19), 31478. Saleh, M. K., Hasan, A. H., & Noaman, N. G. (2020). The Positivity Rate of Epstein-Barr Virus Anti-Viral Capsid Antigen IgG among Children with Infectious Mononucleosis in Diyala-Iraq. Advances in Microbiology, 10(3), 53-59. Turtle, C. J., Hanafi, L. A., Berger, C., Hudecek, M., Pender, B., Robinson, E., ... & Soma, L. (2016). Immunotherapy of non-Hodgkin’s lymphoma with a defined ratio of CD8+ and CD4+ CD19-specific chimeric antigen receptor–modified T cells. Science translational medicine, 8(355), 355ra116-355ra116.  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:48pm Manage Discussion Entry Well stated distinctions for these differential diagnoses Jennifer:) o Collapse SubdiscussionLeslie Clark Leslie Clark Mar 19, 2020Mar 19 at 9:11pm Manage Discussion Entry NR 602 Week 3 Shamma,             The top three differential diagnoses I would choose for your case presentation are acute rhinosinusitis (ARS), mononucleosis, and viral upper respiratory infection.  ARS can have a viral or bacterial source (acute bacterial rhinosinusitis), which determines the course of treatment.  Symptoms of ARS can include purulent nasal secretions, visualization of purulent drainage to the posterior pharynx, and painful teeth, with the latter of the symptoms most indicative of a bacterial infection (Ebell, McKay, Dale, Guilbalt, & Ermias, 2019).  Other findings for ARS may include headache, sore throat, pain over eyebrows (indicating frontal sinus involvement), and cough (Hollier, 2018).  ARS from a viral origin is self-limiting and usually associated with symptoms that resolve around 10 to 14 days after peaking around three days (Rosenfeld et al., 2015).  The left inguinal lymphadenopathy with bilateral lower extremity rubor has me stumped.  My initial thoughts are lymphadenopathy related to the sinus infection, which could possibly be affecting circulation, but the case study only mentions inguinal lymphadenopathy to the left side.             The second differential diagnosis of infectious mononucleosis (mono) is considered based on C.N.’s complaints and findings of pharyngitis, inguinal lymphadenopathy, headache, white tonsillar exudate, and tender tonsillar nodes.  The patient’s age also is a risk factor, as mono is prevalent in mid to late adolescence.  However, C.N. does not have the classic symptoms of fever or fatigue, nausea, vomiting, or rash (Schwartzkopf, 2018).  Additionally, he has the many other symptoms not associated with mono, including sore gums, postnasal drip, fluid behind his eardrums, and sinus tenderness to palpation.             Viral upper respiratory infections involve clear or purulent nasal discharge and congestion in the presence or absence of a cough.  Other symptoms, including a fever and headache, appear at the beginning of the illness, but often resolve when the respiratory symptoms worsen, often within 24 to 48 hours (Wald et al., 2013).  C.N.’s presentation of purulent nasal discharge, postnasal drip, and headache make me consider a simple upper respiratory infection, however, the tonsillar exudate, tonsillar node tenderness, and inguinal lymphadenopathy put this differential at the bottom of my list.             In planning treatment for my primary diagnosis of acute rhinosinusitis, I look at guidelines from both pediatric and adult recommendations because this patient is 17 years old, six feet, 2 inches tall, and 158lbs.  Because this patient’s symptoms have persisted for a week with no signs of improvement, I tend to think it is a possible bacterial infection.  The American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines recommend supportive therapies for symptomatic relief for both viral and bacterial rhinosinusitis.  Acetaminophen or ibuprofen can be used for pain while topical intranasal steroids can be used to relieve facial pain and nasal congestion.  Additionally, nasal saline irrigations may decrease symptoms.  A watchful waiting approach is beneficial and can reduce unnecessary antibiotic use, however, it should be a shared decision between patient and provider.  The patient can be given an antibiotic prescription to start if not improved within a few days of supportive care (Rosenfeld et al., 2015).  The first-line choice of antibiotic is amoxicillin for both adult and pediatric patients.  A recommended dose for C.N. is amoxicillin 500mg PO three times daily for five to 10 days (Aring & Chan, 2016).  He would be instructed to call with unimproved or worsening symptoms. Thank you. Leslie References Aring, A. M., & Chan, M. M. (2016). Current concepts in adult acute rhinosinusitis. American Family Physician, 94(2), 97-105. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=27419326&site=eds-live&scope=site Ebell, M. H., McKay, B., Dale, A., Guilbalt, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. Annals of Family Medicine, 17(2), 164-172. https://doi.org/10.1370/afm.2354 Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Lafayette, LA: Advanced Practice Education Associates, Inc. Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Kumar, K. A., Kramper, M., . . . Corrigan, M. D. (2015). Clinical practice guideline (update): Adult sinusitis. Otolaryngology-Head and Neck Surgery, 152(2), S1-S39. https://doi.org/10.1177/0194599815572097 Schwartzkopf, J. (2018). Infectious mononucleosis. Journal of the American Academy of Physician Assistants, 31(11), 52-53. doi:10.1097/01.JAA.0000546488.73851.dd Wald, E. R., Applegate, K. E., Bordley, C., Darrow, D. H., Glode, M. P., Marcy, S. M., . . . Weinberg, S. T. (2013). Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics, 132(1), e262-e280. https://doi.org/10.1542/peds.2013-1071  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:50pm Manage Discussion Entry Well stated Leslie. Your mention of clear nasal drainage with viral infections is on point,  however keep in mind sometimes you could have bacterial on top of viral infection. o Collapse SubdiscussionOlga Viego Olga Viego Mar 21, 2020Mar 21 at 5:45am Manage Discussion Entry Hi Shamma Top three (3) differentials based on the information provided Acute sinusitis Allergic rhinosinusitis Acute viral respiratory infection Rationale 0. Acute sinusitis: A frontal headache, rhinorrhea with green discharge, postnasal drip, cough, a history of eczema as a child and seasonal allergies now, with no fever. It is the most likely diagnosis. 1. Allergic rhinitis: Headache, postnasal drip, a history of eczema as a child and seasonal allergies now, with no fever. 2. Acute viral respiratory infection: Cough, difficulty breathing, frontal headache, sore throat, swollen lymph nodes. The primary diagnosis Acute sinusitis is the most likely diagnosis with the abovementioned history and examination findings that supports it the most. The disease entails the inflammation of the paranasal sinuses as a result of either viral, bacterial, or fungal infective processes (Rosenfeld, 2016). It can also be a result of an allergic reaction which is the most likely in this patient as supported by their history of previous allergy and the absence of a fever as in the presentation. In such a condition the nasal mucosa is usually simultaneously affected with concurrent nasal and paranasal inflammation (Rosenfeld, 2016). Therefore the diagnosis is usually rhinosinusitis. The symptoms of the disorder entail nasal blocking and congestion, purulent rhinorrhea, and facial pain or pressure, occasionally malaise, headache, with or without fever (Rosenfeld, 2016). The treatment of presumed viral rhinitis in an acute setting is steam inhalation and topical or systemic vasoconstrictors. The suspected bacterial infection is treated using antibiotics. Symptomatic therapy improves the status of a patient despite the cause of the illness. Decongestants, corticosteroid nasal sprays, and the application of heat and humidity give of nasal blockage and corrects sinus drainage (Rosenfeld, 2016). As stated by Mattos, Ferguson, and Lee (2016), recurrent sinusitis sometimes warrants surgery to improve sinus drainage. A majority of sinusitis in immunocompetent cases is viral. Such persons are at an elevated risk of aggressive fungal or bacterial infection. According to Kou et al. (2018), the diagnosis of sinusitis is typically clinical, but CT and cultures extracted endoscopically or by sinus, a puncture may be performed usually for chronic, refractory, or atypical cases. It is crucial to note that some cases of sinusitis can be averted through hand washing, shunning smoking, and immunization. Treatment The ideal initial therapy for the acute form of the disease is watchful waiting, which is what I would start with since most allergic cases are self-limiting (Kou et al, 2018). Therapy will be started in 7-10 days if symptoms fail to improve with an antibiotic, given the supportive presented purulent nasal discharge as a symptom of bacterial sinusitis (Rosenfeld, 2016).  Before and after antibiotic treatment, concurrent local measures to promote drainage including steam and topical vasoconstrictors are applied (Patel, Hwang, & Deschler, 2017). Pain killers can be useful with facial pain and headaches which are common. Nasal steroids and nasal irrigation may be used to alleviate the symptoms. In a suspected or confirmed bacterial acute case,  antibiotics to use include amoxicillin/clavulanate with doxycycline, or respiratory fluoroquinolones as alternatives for 5 to 7 days in acute sinusitis and for up to 6 weeks in a chronic sinusitis scenario  (Rosenfeld, 2016). Symptoms of acute disease are relieved by drainage and control of infection as the targets of treatment. Home remedies of promoting drainage include steam inhalation, use of hot, wet towels over the affected sinuses; as well as hot beverages to help alleviate nasal vasoconstriction and promote drainage. From the hospital, drainage is enhanced using topical vasoconstrictors, which include phenylephrine 0.25% spray given every 3 hours or oxymetazoline applied every 8 to 12 hours (Patel et al., 2017). They are efficacious and are used for a maximum of 5 days or in a cycle of 3 days on and 3 days off until inflammation abates (Patel et al., 2017). The use of systemic vasoconstrictors, including pseudoephedrine 30 mg orally for adults four times in a day may be done but with less efficacy. Saline nasal irrigation may be done but is uncomfortable, though is better in recurrent sinusitis, for patients who get used to its discomfort and master the complex technique (Patel et al., 2017). Corticosteroid nasal spray is useful but takes at least 10 days to be effective. Refernces Kou, Y. F., Killeen, D., Whittemore, B., Farzal, Z., Booth, T., Swift, D., ... & Shah, G. (2018). Intracranial complications of acute sinusitis in children: the role of endoscopic sinus surgery.International journal of pediatric otorhinolaryngology, 110, 147-151. Mattos, J. L., Ferguson, B. J., & Lee, S. (2016). Predictive factors in patients undergoing endoscopic sinus surgery for odontogenic sinusitis. International forum of allergy & rhinology, 6(7), 697-700. Patel, Z. M., Hwang, P. H., & Deschler, D. G. (2017). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. In L. Kunis (Ed.), UpToDate. Retrieved March 20, 2019, from https://www.uptodate.com/contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-in-adults-treatment Rosenfeld, R. M. (2016). Acute sinusitis in adults. N Engl J Med,375, 962-970.  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:51pm Manage Discussion Entry Olga, The sinus, headachy pain associated with a sinus infection is quite notable and the hallmark of a sinus infection. o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:47pm Manage Discussion Entry Hi Shamma, Thank you for this. I doubt a patient would use the word "rubor". As I have mentioned in the discussion this week please be sure that you consider the chief complaint in the patient words.  Shamma Chery Shamma Chery Mar 22, 2020Mar 22 at 12:44pm Manage Discussion Entry CC "My throat is sore. My body hurts , I have a night sweat and my left groin is hurting " • Collapse SubdiscussionMargeaux German Margeaux German Mar 17, 2020Mar 17 at 5:25pm Manage Discussion Entry Hello Dr. Martin and class, Sick Child Clinical Case: Patient information: NC presents to the clinic with her mother who is the primary historian. CC: Abdominal pain SUBJECTIVE HPI: 7-year-old Hispanic female presents to the clinic complaining of intermittent diffuse abdominal pain for 1 to 2 months. Per the patient’s mother, she has refused to eat due to the abdominal pain following and has lost weight. She was recently seen in the hospital on 2/12/2020 for this complaint and diagnosed with abdominal pain and given omeprazole, but the abdominal pain persists. She has NKA and is taking no current medications. PMH: Food aversion: resolved 2015, Failure to thrive: resolved 2016, and intractable migraine. Social Hx: Lives with mother, father, and maternal grandmother in Florida. Father is starting a new job in Texas and the family will be relocating with him at the end of next week. ROS: General: weight loss noted, denies fever, chills, weakness, or trouble sleeping
HEENT: denies vision changes, discharge, pain, decreased hearing, sore throat, swollen glands
Respiratory: denies cough or wheezing
Cardiovascular: denies chest pain, irregular heartbeat, edema, faintness, or SOB
Gastrointestinal: intermittent abdominal pain and change in appetite, denies N/V/D
Genitourinary: denies blood in urine, difficulty urinating, or frequent urination
Musculoskeletal: denies painful joints, stiffness, crepitus, or weakness
Neurological: denies dizziness, fainting, headache, numbness, or tingling
Dermatology: denies dry skin, itching, or rash
OBJECTIVE
Vitals: Wt- 42.08 lb (19.09 kg), Ht- 49.50 in (125.72 cm), Temp- 99.5 F (37.3 C), BMI- 12.1 Index, HR 92/min, RR 18/min, Oxygen sat- 99 %
Growth chart percentiles: Wt- 2.82%, BMI- 0.04%, Ht- 43.82%.
Tanner staging: not applicable Physical Exam: Underweight for height and age
Lab Findings/Diagnostic Data from hospital visit 2/12/2020:
CBC/CMP: WNL
Sed rate: WNL
Kidney, ureter, and bladder x-ray: Negative
Abdominal ultrasound: Negative
Gastrointestinal panel: + for Norovirus.
H. pylori: pending o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 18, 2020Mar 18 at 11:56am Manage Discussion Entry Hello Margeaux - thank you for this post. I know this sounds redundant but it's a very important part of your documentation. How would you write this chief complaint and patient's word using quotation marks?  Collapse SubdiscussionMargeaux German Margeaux German Mar 18, 2020Mar 18 at 7:17pm Manage Discussion Entry Hello Dr. Martin, You are right, direct quotes from the patient or family is a very important part of the documentation. Chief Complaint: 7-year-old Hispanic female, NC, presents to the clinic with her mother who is the primary historian. Per NC’s mother, NC has been refusing to eat because her “tummy hurts all over” after.  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:52pm Manage Discussion Entry Much improved CC Margeaux!  Margeaux German Margeaux German Mar 20, 2020Mar 20 at 6:36am Manage Discussion Entry Dr. Martin, I realized that the chief complaint should look like this: Chief Complaint: Patient states "my tummy hurts all over when I eat"   o Collapse SubdiscussionVanessa Spingola Vanessa Spingola Mar 19, 2020Mar 19 at 6:16pm Manage Discussion Entry Peer response Differential Diagnoses 0. Norovirus Rationale for    Patient tested positive for norovirus  Abdominal pain present – present in less than 5% of norovirus patients (Robilotti, Deresinski & Pinsky, 2015) Rationale against    No diarrhea – diarrhea present in more than 87% of norovirus cases  No vomiting – vomiting present in more than 25% of norovirus cases  1-2 month duration of symptoms – Norovirus generally resolves in 3-7 days    Fecal excretion of virus without symptoms is common (Robilotti, Deresinski & Pinsky, 2015)   2. Gastroesophageal Reflux Disease (GERD) – Rationale for 3. 1.  Abdominal pain  Pain with eating    Refusal to eat  Associated with failure to thrive (Košec et al., 2020; Rosen et al., 2018) Rationale against    Did not improve with PPI which is the recommended first-line treatment for GERD (Rosen et al., 2018)   3. Celiac Disease (CD) Rationale for 4. 1.  Abdominal pain present in 90% of cases  Malabsorption, failure to thrive, weight loss, suboptimal weight    More prevalent in females    Can be triggered in genetically susceptible children by infection such as Norovirus (Al-Bawardy et al., 2017; Durham & Temples, 2018) Rationale against    No abdominal distension or diarrhea – which are present in up to 50% of cases (Durham & Temples, 2018)     I am leaning toward DDx #3, Celiac Disease (CD) for this patient. Her persistent abdominal pain associated with refusal to eat, history of failure to thrive when she was about 2 years old and very low for age weight indicate malabsorption (Al-Bawardy et al., 2017; Durham & Temples, 2018). CD could have been triggered by a norovirus infection that is still causing her to shed virus in her stool despite no active infection. CD would explain her weight loss, abdominal pain and refusal to eat. Diagnosis is made by screening blood for  antitissue transglutaminase antibody (IgA-TTG), if positive the child is referred to pediatric GI for endoscopic duodenal biopsy (Al-Bawardy et al, 2017).   The treatment for CD is lifelong avoidance of gluten, to less than 50 mg/day (Al-Bawardy et al., 2017). Gluten is found in wheat, barley, gravy, toothpaste, some vitamin and supplement fillers and many other common foods. The gluten free diet (GFD) is a complicated process and can be difficult to adhere to, especially because of hidden gluten sources. Referral to a registered dietitian specializing in CD may help in education and adherence to GFD. It is also recommended that lactose containing products be limited initially due to possible co-morbid lactase deficiency, which will frequently resolve with intestinal healing following the GFD (Al-Bawardy et al., 2017). There is currently no medical treatment for CD, it is entirely diet controlled.  I would educate the parents and the child using resources that are age and intellectually appropriate. This will includes what foods are on the DO NOT EAT list. This education will be provided in written and verbal formal with teach back to ensure understanding. A referral to dietitian will be made for further education. Online resources including those from The Celiac Disease Foundation and American Academy of Pediatrics ( www.celiac.org/ (Links to an external site.) and https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Gluten-Free-Shopping-Tips-for-Parents.aspx)   (Links to an external site.)will be provided. Most patients will expierence an improvment in symptoms in weeks and will have resolution with maintenance of the GFD (Al-Bawardy et al., 2017).  Follow up will be scheduled in 1-2 weeks to assess compliance with and understanding of the GFD and then at monthly intervals to assess weight and nutritional status and diet compliance.  Vanessa Al-Bawardy, B., Codipilly, D. C., Rubio-Tapia, A., Bruining, D. H., Hansel, S. L., & Murray, J. A. (2017). Celiac disease: a clinical review. Abdominal Radiology, 42(2), 351–360. https://doi.org/10.1007/s00261-016-1034-y Durham, J., & Temples, H. S. (2018). Celiac Disease in the Pediatric Population. Journal of Pediatric Health Care, 32(6), 627–631. https://doi.org/10.1016/j.pedhc.2018.04.023 (Links to an external site.) Košec, A., Žaja, O., Matovinović, F., Jelavić, B., & Baudoin, T. (2020). Significance of Extra-Esophageal Symptoms in Pediatric Gastroesophageal Reflux Disease. International Archives of Otorhinolaryngology. https://doi.org/10.1055/s-0039-3402437 Robilotti, E., Deresinski, S., & Pinsky, B. A. (2015). Norovirus. Clinical Microbiology Reviews, 28(1), 134–164. https://doi.org/10.1128/cmr.00075-14 Rosen, R., Vandenplas, Y., Singendonk, M., Cabana, M., DiLorenzo, C., Gottrand, F., Gupta, S., Langendam, M., Staiano, A., Thapar, N., Tipnis, N., & Tabbers, M. (2018). Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 66(3), 516–554. https://doi.org/10.1097/MPG.0000000000001889  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:53pm Manage Discussion Entry Well written post Vanessa. It's prudent for us to consider a G.I. consult for this patient as well. o Olga Viego Olga Viego Mar 21, 2020Mar 21 at 5:47am Manage Discussion Entry Hi Margeaux Top three (3) differentials based on the information provided  Inflammatory bowel disease  Intestinal obstruction  Recurrent norovirus infection Rationale 3. Inflammatory bowel disease (IBD): The patient from her history and examination has longstanding two-month abdominal cramping, weight loss, growth retardation and fever which are all commensurate with a diagnosis of inflammatory bowel disease. 4. Intestinal obstruction: due to the longstanding due to intermittent pain for two months, weakness and associated weight loss, as well as decreased appetite. A fever could mean rupture (Pujahari, 2016). 5. Chronic norovirus infection: positive test, weight loss, abdominal pain, weakness, and a low-grade fever (Woodward, Gkrania‐Klotsas, & Kumararatne, 2017) The primary diagnosis I lean toward IBD as the most likely diagnosis based on the abovementioned rationale. Inflammatory bowel disease (IBD) is a disease including Crohn’s disease and ulcerative colitis (Veereman et al., 2018). It is a chronic ilness featured by recurrent inflammation at various parts of the GI tract that causes diarrhea and abdominal pain. The result of such inflammation is a cell-mediated immune response in the GI mucosa. The exact mechanism of etiology remains unknown but the current evidence process that the intestinal biomes cause an abnormal immune reaction in patients bearing multifactorial genetic inclination. Crohn’s disease and ulcerative colitis are similar but maybe differentiated mostly. Colitis is a term normally applies to inflammatory disease in the colonic may be ulcerative, granulomatous, ischemic, radiation-induced, or infectious In pediatric age groups, it is possible to have a very early onset inflammatory bowel disease (VEOIBD) as a diagnosis. One can distinguish more precisely two levels within the VEOIBD diagnosis which are neonatal IBD in patients younger than 1 month, as well as infantile IBD in patients younger than 2 years old (Kelsen et al., 2017). It is therefore unlikely, being seven years old, that the child in question has (VEOIBD), a kind of IBD that begins in persons under 6 years of age. Treatment According to Veereman et al. (2018), the treatment of a patient with IBD entails supportive care and medications. The classes of applied medications include 5-Aminosalicylic acid, corticosteroids, immunomodulating drugs, biologic agents that are anti-cytokine drugs, sometimes antibiotics which include metronidazole, ciprofloxacin, and probiotics. Specific therapy is stepwise (Veereman et al., 2018). The treatment of this young girl begins with symptomatic relief with a graded escalation of the therapeutic regimen until a response is obtained. Aminosalicylates can be oral, enema, and suppository formulations and are valuable; for the treatment of flares and the maintenance of remission. If symptoms persist the next step is of antibiotics. They must be used sparingly in ulcerative colitis (UC) with their little efficacy and with a raised risk for the development of antibiotic-associated pseudomembranous colitis. It is, however, useful in Crohn’s disease (CD) commonly for perianal disease, fistulas, and intra-abdominal inflammatory masses (Veereman et al., 2018).  The subsequent step with recurrence of signs and symptoms is the use of corticosteroids which can be intravenous, oral, topical, or rectal. That works for acute disease flares only. Subsequently is the use of immunomodulators which are useful for steroid-sparing action in refractory disease; primary treatment for fistulas and maintenance of remission in patients intolerant of or not responsive to aminosalicylates (Vavricka et al., 2017). The successive step is the use of clinical trial agents. They often are disease-specific selecting between either CD or UC. Comprehensive therapy that entails supportive care as stated is highly useful in the treatment of this ilness (Veereman et al., 2018). Most patients and their families are highly interested in diet and stress management which are common in presentation, such as in the patient in question who looks sick and poorly nourished. In her treatment, the yearly influenza vaccination and pneumococcal vaccination will be ensured since the patient has a compromised immune system if on immunomodulation (Bousvaros & Lu, 2017). That is intensified with the use of immunomodulators which depress the immune system in the patient. References Bousvaros, A., & Lu, Y. (2017). Immunizations in the child with inflammatory bowel disease. In P. Mamula, A. Grossman, R. Baldassano, J. Kelsen & J. Markowitz (Eds.) Pediatric Inflammatory Bowel Disease(pp. 663-668). Springer. Vavricka, S. R., Gubler, M., Gantenbein, C., Spoerri, M., Froehlich, F., Seibold, F., ... & Juillerat, P. (2017). Anti-TNF treatment for extraintestinal manifestations of inflammatory bowel disease in the Swiss IBD Cohort Study. Inflammatory bowel diseases, 23(7), 1174-1181.doi: 10.1097/MIB.0000000000001109. Veereman, G., Hauser, B., De Greef, E., Devreker, T., Huysentruyt, K., Lemmens, R., & Vandenplas, Y. (2018). Reflections on treatment of IBD in children and adolescents. Immunopharmacology and immunotoxicology, 40(6), 461-464.doi: 10.1080/08923973.2018.1474922 Pujahari A. K. (2016). Decision Making in Bowel Obstruction: A Review. Journal of clinical and diagnostic research : JCDR, 10(11), PE07–PE12. doi: 10.7860/JCDR/2016/22170.8923 Woodward, J., Gkrania-Klotsas, E., & Kumararatne, D. (2017). Chronic norovirus infection and common variable immunodeficiency. Clinical and experimental immunology, 188(3), 363–370. doi: 10.1111/cei.12884 Kelsen, J., Dawany, N., Conrad, M., Sullivan, K., Behrens, E., & Devoto, M. (2017). O-001 A diagnostic approach of immune dysregulation on very early-onset IBD. Inflammatory Bowel Diseases, 23(suppl_1), S1.doi: 10.1097/MIB.0000000000001005 o Margeaux German Margeaux German Mar 22, 2020Mar 22 at 3:59pm Manage Discussion Entry Dr. Martin and class, Summary: The patient in question is a 7-year-old Hispanic female presenting to the clinic with her mother with complaints of “abdominal pain” for 1 to 2 months. This patient refuses to eat because it causes abdominal pain right after eating, resulting in weight loss in this child. Looking at the growth chart percentiles, this child is significantly underweight. Everyone had excellent and thought-provoking responses in their possible diagnosis of this patient. Vanessa, you had excellent differential diagnoses of Norovirus, GERD, and Celiac disease. Olga, you also had excellent differential diagnoses of Inflammatory bowel disease, intestinal obstruction, and recurrent norovirus infection. All of these differentials can be attributed to the patient’s complaints of intermittent abdominal pain. The growth percentile is alarming and shows the patient is severely underweight. On her physical exam, the patient appears to be well hydrated and the abdominal pain has been off and on for almost 2 months. This patient should receive a referral to Gastroenterology to further understand the extent of her abdominal pain (Reust & Williams, 2018). The primary diagnosis is functional abdominal pain at this time due to the patient’s signs and symptoms, the majority of negative diagnostic results, positive for norovirus, and pending H pylori test (Reust & Williams, 2018). The H pylori test will have to be redone since the patient was taking omeprazole during that time and could cause a false negative. For this diagnosis, treatment can begin with a daily probiotic, such as Lactobacillus, to help reduce abdominal pain with eating (Reust & Williams, 2018). Another treatment option is to begin cognitive behavior therapy and hypnotherapy to assist in improving abdominal pain (Reust & Williams, 2018). The goal of the treatment is to minimize the abdominal pain and reassure the patient and family that this is being addressed, and to establish healthy eating patterns again (Reust & Williams, 2018). Reference Reust, C. E., Williams, A. (2018). Recurrent abdominal pain in children. American Family Physician, 97(12), 785-793A. • Collapse SubdiscussionOlga Viego Olga Viego Mar 18, 2020Mar 18 at 7:02am Manage Discussion Entry Patient Information: 1. T., 13-year-old Caucasian Male Subjective: Chief Complaint:  A nonproductive cough, sore throat, and headache. HPI: JT is a 13-year old Caucasian male presenting to the facility in the company of his parents with complaints of a nonproductive cough, mild sore throat, and occasional headache for two weeks. Symptoms have a gradual onset. Parents deny any exposure to smoke or significant dust. The patient is a referral from a primary care center where he is previously seen by a family nurse practitioner and started on Augmentin and then ZIthromax with no apparent alleviation of signs and symptoms after what is now five days of Zithromax. The concerned parents returned him to his clinic from where the boy is referred to here. Allergies: No known drug or food allergies but has a history of seasonal allergic asthma. Current Medications: 500mg OD PO on day 1, followed by 250mg OD PO on days 2 through 5 which is today. Immunizations: Up-to-date PMH: Seasonal asthma attacks from the age of 2 years to now. Currently no increased use of an inhaler. PSHx:No past surgical history Soc Hx: Lives with mother and father and one 5-year old brother. Parents report him as an active child who has refused bed rest. Attends school every weekday, including this time of illness. father and brother have been sick, but with GI symptoms of diarrhea and vomiting. Fam Hx:Father:No PMHx; Mother:Has a history of asthma during childhood, experiences mild atopic dermatitis; Paternal Father:HTN and Type 2 DM; Paternal Mother:No PMHx; Maternal Father:HTN, type 2 DM, and cardiomyopathy; Maternal Mother:No PMHx ROS: CONSTITUTIONAL: The mother reports that he seems well and feeds, drinks, and plays as usual except when he is at rest whereby his cough is more pronounced and she notices mild distress during breathing. The boy, furthermore, reports episodes of headaches that weigh him down sometimes in school and at home. SKIN: Self-reports as normal. HEENT: Dry cough with sneezing and a mildly painful sore throat as self-reported. The mother reports him having painful bilateral neck swelling. RESPIRATORY:The mother reports audible wheezes from his chest. There is some cervical lymphadenopathy bilaterally. GASTROINTESTINAL: Self-reports normal appetite. No vomiting or diarrhea. GENITOURINARY: Self-reports as normal. Objective: Physical Exam: Vital Signs:BP: 100/70, T: 98.5 (rectal), HR: 64, RR 18, SpO2: 95% on room air Length:157.5 cm (62.0 in); Weight:50.3 kg (111.0 lbs.) Growth Chart Percentiles:64% Length for Age; 71% Weight for Age; BMI is 20.3 to reflect an ideal amount of body weight. General:The child is alert and quiet, appropriate for age with an ill and fatigued appearance. He is well-nourished, well-developed, and dressed and groomed appropriately. No signs and symptoms of acute distress noted. HEENT:Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact, sclera non-injected. External auditory canal normal, bilateral TMs intact, Bilateral nares patent, nasal mucosa erythematous and moist, bilateral turbinates edematous and erythematic with clear nasal drainage.  Lymphadenopathy noted on cervical nodes bilaterally. Oral mucosa pink and dry, no cobblestoning or tonsilar exudate. Skin:Warm and dry, no lesions. CV:Regular rate and rhythm, S1/S2, no heart murmur appreciated. Respiratory:Respirations are regular and labored, respiratory rate is normal at about 18, diffuse inspiratory and expiratory wheezes in all lung fields. Abdomen:Soft, non-tender, non-distended, normoactive bowel sounds x 4. No organomegaly or masses palpated. Diagnostic or Lab results:  CXR from 3 days ago reveals left lower lobe opacity and possible atelectasis. RSV, influenza, and rapid strep tests all negative o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 18, 2020Mar 18 at 11:56am Manage Discussion Entry Olga - thank you for this post. Please rewrite your chief complaint using the patients words and quotation marks.  As this is a child, you may also use the mother's or the parent's words.  Olga Viego Olga Viego Mar 22, 2020Mar 22 at 7:21pm Manage Discussion Entry Patient Information: 1. T., 13-year-old caucasian Male Subjective: Chief Complaint:  “I just have a dry cough, sore throat, and headache all for two weeks.” HPI: JT is a 13-year old caucasian male presenting to the facility in the company of his parents with complaints of a nonproductive cough, mild sore throat, and occasional headache for two weeks. symptoms have a gradual onset. Parents deny any exposure to smoke or significant dust. The patient is a referral from a primary care center where he is previously seen by a family nurse practitioner and started on Augmentin and then ZIthromax with no apparent alleviation of signs and symptoms after what is now five days of Zithromax. The concerned parents returned him to his clinic from where the boy is referred to here. Allergies: No known drug or food allergies but has a history of seasonal allergic asthma. Current Medications: 500mg OD PO on day 1, followed by 250mg OD PO on days 2 through 5 which is today. Immunizations: Up-to-date PMH: Seasonal asthma attacks from the age of 2 years to now. Currently no increased use of an inhaler. PSHx:No past surgical history Soc Hx: Lives with mother and father and one 5-year old brother. Parents report him as an active child who has refused bedrest. Attends school every weekday, including this time of illness. father and brother have been sick, but with GI symptoms of diarrhea and vomiting. Fam Hx:Father:No PMHx; Mother:Has a history of asthma during childhood, experiences mild atopic dermatitis; Paternal Father:HTN and Type 2 DM; Paternal Mother:No PMHx; Maternal Father:HTN, type 2 DM, and cardiomyopathy; Maternal Mother:No PMHx ROS: CONSTITUTIONAL: The mother reports that he seems well and feeds, drinks, and plays as usual except when he is at rest whereby his cough is more pronounced and she notices mild distress during breathing. The boy, furthermore, reports episodes of headaches that weigh him down sometimes in school and at home. SKIN: Self-reports as normal. HEENT: Dry cough with sneezing and a mildly painful sore throat as self-reported.The mother reports him having painful bilateral neck swelling. RESPIRATORY:The mother reports audible wheezes from his chest. There is some cervical lymphadenopathy bilaterally. GASTROINTESTINAL: Self-reports normal appetite. No vomiting or diarrhea. GENITOURINARY: Self-reports as normal. Objective: Physical Exam: Vital Signs:BP: 100/70, T: 98.5 (rectal), HR: 64, RR 18, SpO2: 95% on room air Length:157.5 cm (62.0  in); Weight:50.3 kg (111.0 lbs.) Growth Chart Percentiles:64% Length for Age; 71% Weight for Age; BMI is 20.3 to reflect an ideal amount of body weight. General:The child is alert and quiet, appropriate for age with an ill and fatigued appearance. He is well-nourished, well-developed, and dressed and groomed appropriately. No signs and symptoms of acute distress noted. HEENT:Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact, sclera non-injected. External auditory canal normal, bilateral TMs intact, Bilateral nares patent, nasal mucosa erythematous and moist, bilateral turbinates edematous and erythematic with clear nasal drainage.  lymphadenopathy noted on cervical nodes bilaterally. Oral mucosa pink and dry, no cobblestoning or tonsilar exudate. Skin:Warm and dry, no lesions. CV:Regular rate and rhythm, S1/S2, no heart murmur appreciated. Respiratory:Respirations are regular and labored, respiratory rate is normal at about 18, diffuse inspiratory and expiratory wheezes in all lung fields. Abdomen:Soft, non-tender, non-distended, normoactive bowel sounds x 4. No organomegaly or masses palpated. Diagnostic or Lab results:  CXR from 3 days ago reveals left lower lobe opacity and possible atelectasis. RSV, influenza, and rapid strep tests all negative o Shamma Chery Shamma Chery Mar 20, 2020Mar 20 at 9:27pm Manage Discussion Entry As far as a Primary Diagnoses, i come up with  acute sinusitis . His Secondary Diagnosis included dysfunction of both eustachian tube  and third diagnosis is  localized enlarged lymph nodes . In order to diagnose this patient with sinusitis, we had to just use physical assessment, his complaints, and our critical thinking skills. For treatment, we prescribed Augmentin 875-125 MG Oral Tablet for sinus infection, Take 1 tablet (875 mg) by mouth every 12 hours for 10 days, Dispense # 20 tablets, Refills: 0. Since we weren't a hundred percent sure why this patient had dependent edema and swollen lymph nodes in his groin, we didn't prescribe any medications for that, but we did refer to someone who can figure out what was going on there. Education included rest, increase fluids, Claritin am, Benadryl pm, Motrin for comfort, change toothbrush in 3 days, salt water gargles, good handwashing, do not share cups, utensils, straws, or anything by mouth, etc., yogurt or probiotics while on antibiotic therapy, note provided for work and scanned into chart. Activity included rest and activity as tolerated. As far as referrals, for sinusitis, we don't typically refer unless the sinusitis is recurrent. Then we might refer to ENT for further evaluation for frequent infections Reference Patel, Z., & Hwang, P. (2018, February). Acute sinusitis (sinus infection) (Beyond the Basics). Retrieved from https://www.uptodate.com/contents/acute-sinusitis-sinus-infection-beyond-the-basics         o Liz Cannon Liz Cannon Mar 21, 2020Mar 21 at 10:21pm Manage Discussion Entry Olga, Thank you for your great presentation. In this peer response we start by including our top three differentials based on the information provided along with our rationale based on presentation findings: Pertinent positives for your 13-year-old W M patient: History of seasonal asthma attacks since he was 2 years old. Current antibiotics have not provided relief. ROS pertinent complaints: pronounced cough at rest with mild distress during breathing, reporting episodes of headaches that weigh him down, cough is dry with sneezing and mildly painful sore throat. Painful bilateral neck swelling and audible wheezes from chest per parent. Objective pertinent findings: General appearance is ill and fatigued Nasal mucosa erythematous and moist, bilateral turbinates edematous and erythematic with clear nasal drainage Bilateral Cervical lymphadenopathy and regular but labored respirations with diffuse inspiratory and expiratory wheezes in all fields CXR 3 days ago showed left lower lobe opacity and possible atelectasis Negative RSV, influenza, and rapid strep Use of Augmentin and Zithromax have not improved symptoms per parent Based on findings stated above, my top three differentials include the following: Acute asthma exacerbation Findings that support this differential: history of asthma since he was 2 years old, complaint of cough with mild distress during breathing and audible wheezes. Objective findings include ill and fatigued appearance with labored respirations and diffuse inspiratory and expiratory wheezes in all fields. This acute asthma exacerbation, if I may add, is more than likely related to a viral upper respiratory infection which would explain the nasal congestion, headaches, sore throat and lymphadenopathy.  Acute bronchitis (viral) The reason for why viral bronchitis is a possibility is due to the patient’s complaints and current symptoms despite antibiotic treatment. These symptoms include coughing at rest with mild distress, mildly painful sore throat and headache (possibly from all the coughing) along with wheezing in all lung fields and sneezing. Upper respiratory infection (viral): This diagnosis is supported by the headache, sneezing, respiratory difficulties, edematous and erythematic bilateral turbinates with clear nasal drainage. Unfortunately, with asthma as a complication, a simple viral upper respiratory infection can become much worse and include wheezing due to asthma. The primary diagnosis I am leaning towards is acute asthma exacerbation. My reasoning for this is that I believe the patient started with a viral respiratory illness that became complicated by asthma. That being said, my treatment plan still includes consideration for the original illness. In office treatment: Had the patient’s O2 sats been lower, I would have provided him with a single dose of nebulizer treatment using Ipratropium bromide (Runde and Rallo, 2018). Treatment plan: 1.    Finish prescribed Augmentin antibiotic regimen with a probiotic (yogurt works as well) 2.    Fluticasone Nasal Spray 1 spray in each nostril, once a day Refill: 0 (Tesse, Borrelli, Mongelli, Mastrorilli and Cardinale, 2018).   3.    Albuterol Sulfate HFA 90mcg/ Inhalation Aerosol 2 puffs every 4-6 hours as needed for shortness of breath Refill: 1 (Tesse, Borrelli, Mongelli, Mastrorilli and Cardinale, 2018).   4.    Humidifier in the room at night 5.    Elevated head of bed at night to help him sleep better 6.    Keep well hydrated 7.    Honey with lemon in decaffeinated tea for his throat 8.    Ibuprofen 400mg po every 6 hours as needed for pain/fever Limit or eliminate intake of milk, juices and soda until cough is gone. Thank you. References:  Runde, D. and Rallo, M. (2018). Combined Inhaled Short-Acting Beta2 Agonist and Anticholinergic Agents for Asthma. American Family Physician.97(11): online. Tesse, R., Borrelli, G., Mongelli, G., Mastrorilli, V. and Cardinale, F. (2018). Treating Pediatric Asthma According Guidelines. Frontiers in Pediatrics, 6, 234. https://doi.org/10.3389/fped.2018.00234   o Olga Viego Olga Viego Mar 22, 2020Mar 22 at 7:21pm Manage Discussion Entry To summarize, the patient is JT, a 13-year old Caucasian male presenting to the facility with a nonproductive cough, mild sore throat, occasional headache for two weeks, as well as a painful bilateral neck swelling, without a history of exposure to smoke or significant dust. He was previously treated with Augmentin and Zithromax without improvement. He has a positive history of asthma and similar familial history. On examination, of significance is that he has regular and labored breathing with diffuse bilateral inspiratory and expiratory wheezes. Chest radiography reveals left lower lobe opacity and possible atelectasis. Primary diagnosis Adenovirus pneumonia J12.0 The patient is likely to have pneumonia due to a virus in the respiratory tract. Adenovirus is among the commonest viral causes of pneumonia. The patient, in question, on applying empirical evidence and critical thinking shows clinical and investigational findings in keeping with the illness. JT shows typical presenting symptoms of fever, chills, nonproductive cough, sore throat, rhinitis, headaches, and fatigue (Self et al., 2016). Tachypnea and/or dyspnea, wheezing, and acute respiratory distress may be revealed on examination in the disease (Self et al., 2016). JT’s family, in addition, is reportedly showing a current pattern of gastrointestinal infection which is one of the ways adenoviruses invades the body, in the GI tract. In keeping with findings by Schooler, Davis, Parente, and Lee (2017), the diagnosis of viral pneumonia in a suspected presentation is conformed through lab studies and imaging. According to Schooler et al. (2017) the radiographic presentation of lower lobe opacity and possible atelectasis are typical for adenovirus in viral pneumonia in children of JT’s age, making it highly suspicious Secondary diagnoses Respiratory syncytial virus (RSV) B97.4 Possible secondary diagnoses include respiratory syncytial virus (RSV) and influenza viruses A and B (Self et al,, 2016).  RSV typically results in seasonal lower respiratory tract disease, especially infants and children like JT. The illness may occasionally be asymptomatic, mild, or severe, to include also bronchiolitis and pneumonia. The diagnosis is ordinarily clinical though lab tests and imaging may be contributory. Treatment is usually supportive (Barr, Graham, & Mallory, 2019). The patient may not have RSV as the radiographic finding resembling atelectasis is atypical in RSV. Also, there is no mention of a seasonal or outbreak pattern in JT’s presentation. Influenza J11.1 Influenza is a viral respiratory infection that manifests with fever resulting in fever, coryza, cough, headache, and malaise. Diagnosis typically depends on clonal presentation as well as epidemiology since it follows outbreak patterns (Moodley, Bradley, & Kimberlin, 2018). The influenza vaccine is recommended for anyone aged 6months and above. Antiviral treatment lowers the duration of illness by around day and must be considered in high-risk patients (Moodley et al., 2018).  It is unlikely that the subject patient has the most common cause of community-acquired pneumonia remains Streptococcus pneumoniae, after having received potent antimicrobial including augmentin against suspected pneumococcal infection with no resolution. Plan In JT’s presentation, lab investigations may be foregone. However local epidemiology shall be important to observe so as to rule out influenza which adapts seasonal and epidemic patterns. Typical Lab methods used include cytologic evaluation, viral culture, rapid antigen detection, serology, and polymerase chain reaction (PCR) assay. PCR is predictive of the diagnosis of adenovirus infection (Self et al., 2016). Definitive diagnosis is costly and unnecessary in JT since symptomatic treatment is the key therapy, having established the syndrome of presentation. Identification of the virus would only be considered in special cases such as in an immunocompromised case to guide required treatment, or in an outbreak situation following area guidelines to establish if illness is influenza or rule out similar outbreaks such as the current SARS-CoV-2 disease caused by COVID-19 coronavirus. Polymerase chain reaction (PCR)-based tests of viral pathogens are utilized in a single or multiplex panel in many clinical labs (Schooler eta al., 2017). Available in many clinical laboratories. Such tests are rapid and more predictive than clinical diagnoses and different point-of-care tests. Cell culture or serologic tests are less utilized for being slower than PCR analyses but have some value in epidemiologic surveillance Treatment Having made a diagnosis in the patient. Treatment will be primarily supportive since the patient is not immunocompromised to warrant antivirals (Chappell, 2017). Needed supportive care involves in the patient is rest, antipyretics, analgesics, rich and diverse nutrition, and close observation. Resolution should typically occur in 2-3 weeks.  Analgesics to give is acetaminophen (Tylenol) 500mg three times a day for a week for fever and aches. They must avoid aspirin for the risk of Reye’s syndrome. Education The child and parent/guardian must be educated. JT shall need bed rest, drink fluids especially hot beverages, as well as. Otherwise, the parent and the child should remember to wash their hands often. The child should stay away from school until symptoms subside, and get the flu vaccine. Referral  Referral to a pediatrician has required if the patient has audible stridor even when calm and at rest or exhibits danger signs including an inability to feed (Self et al., 2016). A cough for more than 30 days also warrants referral for further assessment of tuberculosis plus other chronic diseases. Follow-up According to Self et al. (2016), if the child shows no improvement in symptoms after 2 weeks or has an aggravation of symptoms into the abovementioned danger signs, they require a review for a referral. References Barr, F. E., Graham, B. S., & Mallory, G. B. (2019). Respiratory syncytial virus infection: Treatment. In M. S. Edwards, G. B. Mallory, & M. M. Torchia (Eds.), UpToDate. Retrieved March 21, 2019, from https://www.uptodate.com/contents/respiratory-syncytial-virus-infection-treatment Chappell, F. (2017). The treatment of URTIs and otitis media in children. Prescriber, 28(3), 40-44. Moodley, A., Bradley, J. S., & Kimberlin, D. W. (2018). Antiviral treatment of childhood influenza: an update. Current opinion in pediatrics, 30(3), 438-447. Rosenfeld, R. M. (2016). Acute sinusitis in adults. N Engl J Med, 375, 962-970. Schooler, G. R., Davis, J. T., Parente, V. M., & Lee, E. Y. (2017). Children with cough and fever: up-to-date imaging evaluation and management. Radiologic Clinics, 55(4), 645-655. Self, W. H., Williams, D. J., Zhu, Y., Ampofo, K., Pavia, A. T., Chappell, J. D., ... & Erdman, D. (2016). Respiratory viral detection in children and adults: Comparing asymptomatic controls and patients with community-acquired pneumonia.The Journal of infectious diseases, 213(4), 584-591.   • Collapse SubdiscussionSamantha Bouie Samantha Bouie Mar 18, 2020Mar 18 at 1:06pm Manage Discussion Entry Hello Dr. Martin & Class! Chief Complaint/Concern (CC): N.C presents to the clinic today with the chief complaint of abdominal pain and follow up from an ER visit. History of Present Illness (HPI): Patient is a 7-year old Hispanic female that presents with abdominal pain that which is described as diffuse in nature and that has been occurring intermittently over the past two months. Mother reports weight loss and that patient refuses to eat because patient gets abdominal pain after eating. On 1/12/2020, patient was taken to Baptist Kendall Hospital for the same chief complaint and received a diagnosis of abdominal pain and given a prescription for Omeprazole. Review of Systems (ROS): General: Weight loss noted, Afebrile HEENT: Denies sore throat, swollen glands,                Denies blurred vision, pain, or discharge                Denies decreased hearing RESPIRATORY: Denies cough or shortness of breath CARDIOVASCULAR: Denies chest pain, SOB, irregular heartbeat GASTROINTESTINAL: On and off abdominal pain, denies diarrhea, nausea, vomiting GENITOURINARY: Denies difficulty urinating, hematuria, frequency MUSCULOSKELETAL: Moves all extremities, Denies painful joints or weakness NEUROLOGICAL: Denies Dizziness, fainting, headache INTEGUMENTARY: Denies itching, dry skin, rash Objective/Physical Exam: Vitals: Temp 99.5 F                HR 92                RR 18                Spo2 99% on RA Growth Chart: Wt. 42.08 lb (19.09 kg), Ht 49.50 in (125.72 cm)                Wt 2.82%, BMI 0.04%, Ht 43.82%. Tanner Staging: N/A General: Alert, well-hydrated, no sign of distress, appears non-toxic HEENT: Head appears normocephalic, atraumatic Eyes: PERRLA, sclera non-icteric Ears: WNL Throat: WNL Neck/thyroid: neck supple, full ROM, no cervical lymphadenopathy Respiratory: Lung sounds clear bilaterally Cardiovascular: S1, S2 WNL, regular rate and rhythm, no heart murmurs noted Gastrointestinal: soft abdomen, nontender, nondistended, bowel sounds present X 4, normal, negative rovsing sign, no guarding, negative psoas sign Extremities: no clubbing, no cyanosis, no edema Neurological: nonfocal, motor strength WNL upper and lower extremities, sensory exam intact Lab Findings/Diagnostic Data from hospital visit:                CBC/CMP: WNL                Sed rate: WNL                KUB: negative                Abdominal ultrasound: negative                Gastrointestinal panel: + for Norovirus.                Pending: H. pylori results done at Pediatric Associates Thank you! Samantha Bouie    o Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:55pm Manage Discussion Entry Hi Samantha- nice work however please avoid using the initials WNL. While tempting, it is still much better to use descriptive terminology you have learned in your courses, including physical assessment, to describe your findings. • Collapse SubdiscussionSamantha Bouie Samantha Bouie Mar 18, 2020Mar 18 at 1:18pm Manage Discussion Entry ORIGINAL POST EDIT: Hello everyone! I had to edit my initial because I accidentally left out some of the components of the HPI! I apologize about that!  Chief Complaint/Concern (CC): Patient presents to the clinic today with the chief complaint of abdominal pain and follow up from an ER visit. History of Present Illness (HPI): Patient is a 7-year old Hispanic female that presents with “on and off” abdominal pain that which is described as diffuse in nature and that has been occurring intermittently over the past two months. Mother reports weight loss and that patient refuses to eat because patient gets abdominal pain after eating. On 1/12/2020, patient was taken to Baptist Kendall Hospital for the same chief complaint and received a diagnosis of abdominal pain and given a prescription for Omeprazole. Allergies: No known drug, food or environmental allergies Medications: None Past Medical History (PMI): Food aversion (resolved 2/2015), Failure to thrive (resolved 2/2016) Intractable Migraine Social History: Currently lives with mother and grandmother. Father works as a mechanic and lives in Orlando. Family moving to Houston, Texas at the end of the week due to Father getting a new job with BMW Review of Systems (ROS): General: Weight loss noted, Afebrile HEENT: Denies sore throat, swollen glands,                Denies blurred vision, pain, or discharge                Denies decreased hearing RESPIRATORY: Denies cough or shortness of breath CARDIOVASCULAR: Denies chest pain, SOB, irregular heartbeat GASTROINTESTINAL: On and off abdominal pain, denies diarrhea, nausea, vomiting GENITOURINARY: Denies difficulty urinating, hematuria, frequency MUSCULOSKELETAL: Moves all extremities, Denies painful joints or weakness NEUROLOGICAL: Denies Dizziness, fainting, headache INTEGUMENTARY: Denies itching, dry skin, rash Objective/Physical Exam: Vitals: Temp 99.5 F HR 92 RR 18 Spo2 99% on RA Growth Chart: Wt. 42.08 lb (19.09 kg), Ht 49.50 in (125.72 cm)             Wt 2.82%, BMI 0.04%, Ht 43.82%. Tanner Staging: N/A General: Alert, well-hydrated, no sign of distress, appears non-toxic HEENT: Head appears normocephalic, atraumatic                Eyes: PERRLA, sclera non-icteric                Ears: WNL                Throat: WNL                Neck/thyroid: neck supple, full ROM, no cervical lymphadenopathy Respiratory: Lung sounds clear bilaterally Cardiovascular: S1, S2 WNL, regular rate and rhythm, no heart murmurs noted Gastrointestinal: soft abdomen, nontender, nondistended, bowel sounds present X 4, normal, negative rovsing sign, no guarding, negative psoas sign Extremities: no clubbing, no cyanosis, no edema Neurological: nonfocal, motor strength WNL upper and lower extremities, sensory exam intact Lab Findings/Diagnostic Data from hospital visit:                CBC/CMP: WNL                Sed rate: WNL                KUB: negative                Abdominal ultrasound: negative                Gastrointestinal panel: + for Norovirus.                Pending: H. pylori results done at Pediatric Associates Thank you so much! ~Samantha Bouie o Mary Brigid Martin Mary Brigid Martin Mar 19, 2020Mar 19 at 4:03pm Manage Discussion Entry Samantha Thanks for this - you wrote:  Patient is a 7-year old Hispanic female that presents with abdominal pain that which is described as diffuse in nature and that has been occurring intermittently over the past two months. Mother reports weight loss and that patient refuses to eat because patient gets abdominal pain after eating. On 1/12/2020, patient was taken to Baptist Kendall Hospital for the same chief complaint and received a diagnosis of abdominal pain and given a prescription for Omeprazole.      In your symptom analysis did anything make the symptoms better or worse? o Leslie Clark Leslie Clark Mar 20, 2020Mar 20 at 4:17pm Manage Discussion Entry NR 602 Week 3 Samantha,             The three differential diagnoses for your case study include functional abdominal pain (FAP), peptic ulcer disease, and gastro-esophageal reflux disease (GERD).  I chose FAP based on your patient (and mother’s) reports of intermittent abdominal pain for two months, negative exam findings while hospitalized and at the current office follow-up visit, and experiencing the stressful situations of living away from her father coupled with an upcoming move to a different state.  Diagnostic standards using the Rome criteria include episodic pain for two months, not enough criteria to diagnose other functional gastrointestinal disorders, and no evidence of anti-inflammatory or other disease processes (Burns, Dunn, Brady, Starr, Blosser, & Garzon, 2017).  N. C. does have the red flag symptom of unintentional weight loss, though the mother reports the patient is not eating due to fear of pain.  At the time of her hospitalization, her norovirus test was positive, but her lab work, ultrasound, and x-ray were all negative for any type of disease process.  She was trialed on a proton pump inhibitor which was unsuccessful.  Oswari et al. (2019) identified FAP disorders as lacking an organic cause for patients’ pain symptoms.  It was noted to be more common in females and a significant association between FAP and loss of appetite was identified.  Additionally, an association was made between FAP and psychological stress, especially stressful family situations.             I considered peptic ulcer disease due to her symptoms of abdominal pain with eating, vague, diffuse pain, and intermittent symptoms.  However, she did not complain of nocturnal pain, blood in her stools, vomiting, or nausea (Burns, Dunn, Brady, Starr, Blosser, & Garzon, 2017).  Her H. pylori results were still pending, so it would be useful to obtain those from the lab.  The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition’s updated clinical practice guidelines state that when the presence of an actual gastric or duodenal ulcer has been ruled out, patients should not be treated for an H. pylori infection for the sole purpose of improving symptoms (Jones et al., 2017).             GERD is on her list of differentials based on her history of food aversion and failure to thrive, and her current symptoms of abdominal pain and weight loss, and stressful life events.  However, she does not complain of heartburn, regurgitation, difficulty swallowing, or a cough (Burns, Dunn, Brady, Starr, Blosser, & Garzon, 2017).  Additionally, she was trialed on a proton pump inhibitor, which was unsuccessful in improving her symptoms.             Of these differentials, I am inclined to pursue FAP as my primary diagnosis, pending the results of the H. pylori test and repeating the norovirus test to rule out a continued infection.  The first-line treatment for FAP is through a nonpharmacological approach utilizing changes to the diet, instituting probiotics, and cognitive-behavioral therapies (Brusaferro, Farinelli, Zenzeri, Cozzali, & Esposito, 2018).  Because N.C. and her family will be moving at the end of the week, surely to cause her some stress, it is important for her mother to understand the importance of establishing a relationship with a care provider to assist she and N.C. is improving her quality of life.  She must also be provided the results of the H. pylori and repeat norovirus test to be able to rule those out as possible causative factors of the abdominal pain.    Thank you. Leslie   References Brusaferro, A., Farinelli, E., Zenzeri, L., Cozzali, R., & Esposito, S. (2018). The management of paediatric functional abdominal pain disorders: Latest evidence. Paediatric Drugs, 20(3), 235-247. Retrieved from https://search-proquest-com.chamberlainuniversity.idm.oclc.org/docview/2193094534?accountid=147674 Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2017). Pediatric Primary Care (6th ed.). St. Louis, Missouri: Elsevier Jones, N. L., Koletzko, S., Goodman, K., Bontems, P., Cadranel, S., Casswall, T., . . . Rowland, M. (2017). Joint ESPGHAN/NASPGHAN guidelines for the management of helicobacter pylori in children and adolescents (update 2016). Journal of Pediatric Gastroenterology and Nutrition, 64(6), 991-1003. doi:10.1097/MPG.0000000000001594 Oswari, H., Alatas, F. S., Hegar, B., Cheng, W., Pramadyani, A., Benninga, A., & Rajindrajith, S. (2019). Functional abdominal pain disorders in adolescents in Indonesia and their association with family related stress. BMC Pediatrics, 19(1), 1-9. doi:10.1186/s12887-019-1682-5 o Samantha Bouie Samantha Bouie Mar 22, 2020Mar 22 at 11:39pm Manage Discussion Entry Summary Hello Dr. Martin and Class,  We are presented with a 7-year old Hispanic female that presents with “on and off” abdominal pain that which is described as diffuse in nature and that has been occurring intermittently over the past two months. Mother reports weight loss and that patient refuses to eat because patient gets abdominal pain after eating. On 1/12/2020, patient was taken to Baptist Kendall Hospital for the same chief complaint and received a diagnosis of abdominal pain and given a prescription for Omeprazole. Thank you professor and class for an interesting discussion! Leslie, you chose three differential diagnosis that included functional abdominal pain, gastroesophageal reflux disease, and peptic ulcer disease. Awesome work! These were some of my differentials as well for this patient. Dr. Martin, in my symptom analysis, eating made the symptoms worse. I didn’t note any findings that made the symptoms better.   My primary diagnosis for N.C is functional abdominal pain (FAP). Her pain falls into the chronic category being that it has been occurring intermittently for the past 2 months. FAP is a very common condition found in the pediatric population which may occur with other symptoms such as fatigue, nausea and vomiting. The patient’s belly was non-tender with palpation and she did not complain of any vomiting or diarrhea, which would also help rule out appendicitis and cholecystitis, which typically have a more acute clinical presentation and can present with pain after eating. Also, her diagnostic work-up when she went to the E.R was negative. Yes her weight loss is concerning, however we also know that her mother states the patient is fearful of eating related to anticipation of abdominal pain. No bloody stools or vomiting after eating was mentioned in the case study, which is helpful in ruling out peptic ulcer disease. Gastroesophageal reflux disease may be ruled out because the patient was prescribed Omeprazole the last time she went to the E.R for the same issue and the proton pump inhibitor has not helped (Brusaferro, Farinelli, Zenzeri, Cozzali, & Esposito, 2018). My treatment plan would definitely include referral to a gastroenterologist due to the chronic nature of the pain and the concern for malnutrition related to weight loss. I would also assess socioeconomic factors as well that may be causing stress in the child’s life which research has shown plays a role in the progression of FAP in pediatrics. A positive finding is that the patient was positive for the norovirus, which can cause gastroenteritis. Adding a probiotic would be beneficial as well as education on adequate hydration and an opinion from a GI doctor. Using a patient centered, collaborative approach is helpful in treating this patient. Thank you so much  ~Samantha Bouie References Brusaferro, A., Farinelli, E., Zenzeri, L., Cozzali, R., & Esposito, S. (2018). The Management of Paediatric Functional Abdominal Pain Disorders: Latest Evidence. Paediatric drugs, 20(3), 235–247. Retrieved from www.ncbi.nlm.nih.gov • Collapse SubdiscussionLeslie Clark Leslie Clark Mar 18, 2020Mar 18 at 3:56pm Manage Discussion Entry NR 602 Week 3 Sick Child Case Presentation Dr. Martin and Class,             Following is the information for the case presentation. Thank you.   8-year-old African American male Subjective: C.C. Severe joint pain HPI Patient presents with mother who reports severe, constant pain to both of patient’s knees, elbows, and ankles starting two days ago after playing basketball; patient denies any injury; the pain worsens with movement and is temporarily relieved by Tylenol; mother also reports patient has no energy and is not eating Current medications Children’s Tylenol per package dosing q4h prn pain PMHx circumcision, no known allergies, immunizations UTD except last influenza (November 2017) Soc Hx Second-grade student, enjoys math and reading Fam Hx Mother: HTN Father: unknown Maternal grandparents: DM, HTN Paternal grandparents: HTN, hyperlipidemia, DM ROS   Constitutional + lethargy, + fatigue Skin No rash, bruising, or bleeding HEENT No otorrhea, congestion, or sore throat Respiratory No cough or SOB Neuro No confusion, HA, gait or balance issues Cardiovascular No chest pain MSK + painful joints, + pain with movement; no joint redness or difficulty walking, no trauma GI + loss of appetite; no ABD pain, no N/V GU No decrease in UOP   Objective: VS T 98.0 oral HR 108 RR 22 BP 100/72 O2 sat 100% RA Ht/Wt Wt. 25.8kg = approx. 50th percentile Ht. 132cm = approx. 75th percentile BMI 14.8kg/m2 = 25th percentile PE   General Patient appears tired Skin Warm, no clubbing, cyanosis, or edema noted. No deformities or rash. Good skin turgor HEENT Normocephalic, atraumatic; PERRL, EOM intact; no discharge, conjunctivitis, or icterus; no ptosis; + red reflex bil. Clear external auditory canals, pinna normal shape; TMs grey, no erythema or bulging Normal pink mucosa without drainage or blood, septum midline, MM moist No tracheal deviation, no decrease in ROM, no lymphadenopathy or masses palpated Respiratory Lungs CTA bilat., no stridor, wheeze, or crackles, good air movement Neuro Alert and oriented, cooperative, follows commands, answers questions, symmetrical movement to all extremities Cardiovascular + S1/S2, no murmur, cap. refill <2 sec; 2+ pulses to all extremities MSK Full ROM in all extremities, + tenderness GI ABD soft, nontender, +BS to all 4 quadrants GU Deferred   Labs: CBC Hgb 9mg/dL Hct 26 WBC 14,000   Diagnostics: Ultrasound Spleen 8cm in size   o Collapse SubdiscussionLeslie Clark Leslie Clark Mar 19, 2020Mar 19 at 2:29pm Manage Discussion Entry Dr. Martin, In reviewing your questions to my classmates, I see I need to correct the C.C. C.C. "severe joint pain"  Thank you. Leslie    Collapse SubdiscussionDavid Valdes David Valdes Mar 20, 2020Mar 20 at 4:34pm Manage Discussion Entry Leslie Clark,   The presented case was well formulated and allowed for further discussion of this interesting case. Three differential diagnosis will be presented, and a treatment plan will be discussed for the primary diagnosis.   Top three differential diagnosis     1) Rheumatoid Arthritis   Pertinent findings that were presented in the case were that the patient complained of having severe bilateral joint pain that includes his knees, elbows, and ankles. Rheumatoid arthritis typically presents with bilateral joint pain, feeling tired, pain that could be worsened with movement, and can begin acutely (Hollier, 2017). The patient has also been refusing to eat because he has been feeling restless and tired. The patient presented with an elevated total leukocyte count of 14,000 that could be indicative of swelling caused by rheumatoid arthritis (Chmielewski and Strzelec, 2018).   2) Osgood-Schlatter Disease             Pertinent findings that were presented in the case were that the patient was suffering from bilateral keen pain after playing basketball. Osgood-Schlatter disease is more common in adolescent males that are involved in athletic sports that require repetitive jumping (Hollier, 2016). Basketball involves regularly jumping and could be an aggravating factor for this disease. The patient is at an age where rapid bone growth is occurring and an increase in pressure is being displaced onto the patellar tendon that could result in pain (Circi et al., 2017).   3) Juvenile Idiopathic Arthritis                  Pertinent findings that were presented in the case were that the patient was feeling pain in his bilateral joints of the hands, knees, and ankles after playing basketball and feeling fatigued. Typical findings, in which the patient had, included an appetite loss, pain worsening after waking up, and having an elevated white blood count (Arthritis Foundation, 2019). The patient presented with an elevated leukocyte count of 14,000 that supports this differential diagnosis.               The primary diagnosis that I am leaning towards is rheumatoid arthritis. From the bilateral joint pain to feeling tired, the patient’s symptoms are consistent with this auto-immune disease. The healthcare provider can develop a treatment plan for this patient. Although the patient had an ultrasound performed, an x-ray is indicated to help further evaluate the patient’s joints. An x-ray will help assess the spacing of his joints and bony erosion of his joints (Hollier, 2016). Blood work would also be collected to assess for the patient’s erythrocyte rate, rheumatoid factor, and C-reactive protein, which would help determine if an inflammatory process is occurring (Burmester and Pope, 2017).             The healthcare provider can also prescribe medications to help treat rheumatoid arthritis and provide comfort for the patient. DMARDS monotherapy is indicated as a first-line treatment for rheumatoid arthritis and the patient can be prescribed etanercept while also prescribing either NSAIDs or steroids (Hollier, 2016). Educating a patient on nonpharmacological interventions is also recommended for patients suffering from rheumatoid arthritis. Educating the patient and family on the implementation of a Mediterranean diet, applying both cold and heat therapy onto the joints, and performing exercises that do not involve the inflamed joint are all measures that can be taken to help provide relief for this disease (Burmester and Pope, 2017).          References   Arthritis Foundation. (2019). Juvenile idiopathic Arthritis. https://arthritis.org/diseases/juvenile-      idiopathic-arthritis Burmester, G. R., & Pope, J. E. (2017). Novel treatment strategies in rheumatoid arthritis. The Lancet,      389(10086), 2338-2348. https://scholar.google.com/scholar?as_ylo=2016&q=rheu      matoid+arthritis+treatment&hl=en&as_sdt=0,10 Chmielewski, P. P., & Strzelec, B. (2018). Elevated leukocyte count as a harbinger of systemic      inflammation, disease progression, and poor prognosis: A review. Folia morphologica, 77(2),      171-178. https://journals.viamedica.pl/folia_morphologica/article/view/54054 Circi, E., Atalay, Y., & Beyzadeoglu, T. (2017). Treatment of Osgood–Schlatter disease: review of the      literature. Musculoskeletal surgery, 101(3), 195-200. https://link.springer.com/article/10.      1007/s12306-017-0479-7 Hollier, A. (2018). Clinical guidelines in primary care (2nd ed.). Advanced Practice       Educational Association, Inc.  Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:56pm Manage Discussion Entry Fine work David - Mediterranean diet is getting a good deal of attention these days. It is very important to give specifics to a patient. Patient education about diet is quite complex and if ever possible, referral to dietary specialists is optimal. o Mary Brigid Martin Mary Brigid Martin Mar 19, 2020Mar 19 at 4:04pm Manage Discussion Entry Leslie and class - please note that the  CC should be in quotes:) o Collapse SubdiscussionLeslie Clark Leslie Clark Mar 22, 2020Mar 22 at 5:34pm Manage Discussion Entry NR 602 Week 3 Summary Dr. Martin and Class, 0. W. is an 8-year-old male coming to the clinic with his mother who reports a two-day history “severe joint pain” of bilateral knees, elbows, and ankles which started after he played basketball. They deny any known trauma or injury and the pain is worsened by movement.  He has also been fatigued with a decreased appetite.  Upon examination, he is mildly tachycardic (heart rate 108), appears tired, and pain is elicited with movement of his joints.  His lab values reveal anemia and leukocytosis with a hemoglobin (Hgb) level of 9, hematocrit (Hct) level of 26, and white blood cell (WBC) count of 14,000.  His spleen is not enlarged, measuring 8cm in size on ultrasound.             His primary diagnosis is juvenile idiopathic arthritis (JIA), a rheumatologic disorder formerly known as juvenile rheumatoid arthritis.  JIA is classified into seven categories and though the cause is unknown, it is suspected to be a result of genetic, immunologic, and environmental factors.  Common presentations of JIA include joint pain, joint inflammation, fever, limping, rash, and abdominal pain.  Patients’ symptoms must be present for six or more weeks (Momah & Ray, 2019).  Though M. W.’s symptoms have only been present for two weeks, his symptoms align well with JIA. A treatment plan for M. W. should include imaging through x-rays of the affected joints to assess for any structural damage or issues with bone growth.  This can be followed with magnetic resonance imaging (MRI), which when used with contrast, can assess for early joint inflammation.  Though various tests can be obtained to assess for inflammation, rheumatoid factor, or certain antibodies, there is not a test used to give a specific and definitive diagnosis of JIA.  Nonsteroidal anti-inflammatory medications and intra-articular steroids can be used for the acute symptoms of swelling, pain, and inflammation; however, they are not a long-term therapy choice.  Treatment options, which are indicated depending on the diagnosed category of JIA, include disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, and anti-interleukin monoclonal antibody drugs (Momah & Ray, 2019).  Because M. W. is early into what is the diagnostic period for JIA and has not had the symptoms for six weeks (required for a diagnosis of JIA), an initial treatment plan would include a trial treatment of:         naproxen 125mg/5ml give 5ml by mouth twice daily administered with food Disp # 150ml Refill: 1 After a four-week treatment period with naproxen, the patient should be reevaluated for continued signs and symptoms of JIA, and if present, a DMARD could be initiated with consideration for referral to a pediatric rheumatologist.             There are no secondary diagnoses being considered for M. W. at this time.  The other differential diagnosis of Osgood-Schlatter disease (OSD) was certainly a possibility with the patient’s complaint of bilateral knee pain, however, he also complains of bilateral elbow and ankle pain, joints not involved with OSD.  Though common in athletes, OSD is an injury at the patella (Achar & Yamanaka, 2019) and is not accompanied by fatigue, anemia, or loss of appetite.  Low impact activities and isometric exercises should be encouraged when active joint inflammation is present and if diagnosed with JIA, physical therapists can be helpful in teaching proper exercises (Viswanathan & Murray, 2016).             Thank you, David, for your response to my post.  Your differential diagnoses of rheumatoid arthritis, Osgood-Schlatter disease, and juvenile idiopathic arthritis were well thought out and you provided insightful information into each of them.  I appreciate your recommendation of nonpharmacological therapies, including diet modifications and alternative physical activities with education to avoid impacting the affected joints. Thank you. Leslie References Achar, S., & Yamanaka, J. (2019). Apophysitis and osteochondrosis: Common causes of pain in growing bones. American Family Physician, 99(10), 610-618. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=31083875&site=eds-live&scope=site Momah, T., & Ray, L. (2019). Juvenile idiopathic arthritis: Old disease, new tactics. The Journal of Family Practice, 68(2), e8-e13. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=30870545&site=eds-live&scope=site Viswanathan, V., & Murray, K. J. (2016). Management of children with juvenile idiopathic arthritis. Indian Journal of Pediatrics, 83(1), 63-70. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=26639461&site=eds-live&scope=site    Leslie Clark Leslie Clark Mar 22, 2020Mar 22 at 5:37pm Manage Discussion Entry Dr. Martin, I'm not sure why canvas numbered the first paragraph of my post.  It is not numbered in my word document nor did it show up that way before I hit the post button. My apologies. Leslie • Collapse SubdiscussionJennifer Benvin Jennifer Benvin Mar 18, 2020Mar 18 at 4:53pm Manage Discussion Entry Professor and Classmates, This week we are asked to discuss a patient we had seen in our clinical rotations and present it to the class. This week I asked Dr. Martin to please provide me with a case as I did not see anything besides circumcises and newborn assessment.  Application of Course Knowledge  Initial presentation needs to include the following elements: • chief complain/concern, • HPI – • ROS – PE only pertinent positives • Lab/diagnostic data   Patient’s Information MW is an 8-year-old black male  Subjective Chief Complaint Severe joint pain that started 2 days ago after playing basketball HPI: C.C is an 8-year-old black male who was brought into the clinic by his mom who states her son has been complaining of severe joint pain that started 2 days ago after playing basketball. The mother states her son stated the pain is concentrated to bilateral knees, elbows, and ankles. The mother states her son told her it is constant pain. The mother states her son refuses to eat and appears listless and tired. The mother states her son has worsen pain with movement. The mother states the only relieving factors and treatment is Tylenol but the pain return with vengeances. The mother or child does not rate a pain on the pain scale. Allergies: No known drug, food, or environmental allergies Current Medications: no medication reported by mother  Immunizations: current influenza (flu) November 2017.  PMHx: No prior medical history PSHx: No reported past surgical history Soc Hx: Patient is a student in the second grade and love math and reading Fam Hx: Mother: HTN, Father: No PMHx, Maternal grandmother: HTN and Type 2 DM. Maternal grandfather: HTN and Type 2 DM.  Paternal grandmother: HTN, hyperlipidemia, and type 2 DM. Paternal grandfather: HTN, hyperlipidemia, and type 2 DM.  ROS CONSTITUTIONAL Patient’s mother states he has been experiencing bilateral knees, elbows, and ankles pain. The patient’s mother states her son has not been able to eat due to being tired and listless. SKIN None reported HEENT None reported RESPIRATORY None reported NEUROLOGICAL None reported CARDIOVASCULAR None reported MUSCULOSKELETAL Mother reports her son has constant bilateral knees, elbows, and ankles pain. GASTROINTESTINAL Mother reports decrease in appetite GENITOURINARY None reported PSYCH None reported NEUROLOGICAL None reported Objective Physical Exam Vital Signs: None reported Length: None reported Growth Chart Percentiles: None reported Height: None reported BMI:None reported Tanner Staging: Stage 2 General: None reported Skin: None reported HEENT: None reported CV: None reported Respiratory: None reported Abdomen: None reported Neuro: None reported Musculoskeletal: Pain with movement Gastrointestinal: None reported Genitourinary: None reported Psychiatric: None reported Lab/diagnostic data Labs: 
CBC hemoglobin hematocrit of 9mg/dL and 26 percent respectively. 
WBC Total leukocyte count is elevated to 14,000  DIAGNOSTIC FINDINGS 
Ultrasound Splenomegaly (Spleen size of 8cm)  o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 19, 2020Mar 19 at 4:07pm Manage Discussion Entry Jennifer and class,   I realize I have given a few of the students cases, I would like all of you to focus on how a chief complaint could be written in the patient's words, of the parents words. This is a learning exercise!  Jennifer Benvin Jennifer Benvin Mar 20, 2020Mar 20 at 8:58pm Manage Discussion Entry Professor, I did not know the c/c needed to be in "". I am glad you brought this to my attention. For my c/c for my 8 year old male pt it would look like this. The patient's mother states her son complains of "severe joint pain"   Jennifer Benvin o Alisha Durm Alisha Durm Mar 21, 2020Mar 21 at 3:28pm Manage Discussion Entry Hello Jennifer, your case study was interesting. I am not sure if I am correct as many of the symptoms are similar , but I am interested in reading your summary. Most likely diagnosis :Sickle Cell Anemia also know as Sickle Cell Disease (SCD) is a genetic blood disorder in which the red blood cell contains an abnormal hemoglobin called Hemoglobin S (HbS). The abnormal HbS  causes the red blood cells to become stiff, sticky, sickled-shaped. These RBC become stuck together causing an occasion to vessels and impaired tissue oxygenation (García-Morin et al., 2016). As a result, painful vaso-occlusive episodes or sickle cell crisis occur.  In the United States, most people who have sickle cell disease are of African ancestry (Sunghee, Brathwaite & Ook, 2017). Common symptoms of SCD include severe episodes of pain, fatigue, anemia, bacterial infections, priapism, splenic sequestration, dactylitis and arthritis. A Hct of 20% to 29% , Hgb 6 to 10 g/dL and elevated reticulocyte count of 5% to 15% are laboratory finding in patients with SCD (Burns et. al, 2016). Rationale: I chose SCD as my most likely diagnosis based on his race,  the classic symptoms of SCD such as severe episodes of pain, loss of appetite, listless appearance, anemia (CBC 9mg/dL and  hematocrit of 26%), elevated WBC (14,000), and splenomegaly (8cm). Also he experiences some relief with Tylenol and rest but as the pain returned it was uncontrollable. Also the onset of pain after strenuous exercise which places a high oxygen demand on the body lead me to believe that this was a vaso-occlusive crisis.  2nd most likely diagnosis: Leukemia is a heterogeneous group of hematological disorders characterized by the abnormal proliferation of immature cells in the bone marrow, peripheral blood, and other organs. These immature cells cause disruption of normal marrow function and ultimately result in marrow failure (American Cancer Society (ACA), 2020). Initial symptoms are often non-specific, such as fever, fatigue, pallor, or limb and joint pain. Other symptoms include anemia, irritable, have the following a h history of infections, decreased appetite, weight loss, epistaxis, petechiae,  hematomas, lymphadenopathy, and hepatosplenomegaly (ACA, 2020). Rationale: I chose this diagnosis because the clinical presentation of ALL include symptoms of pain, listlessness, fatigue, anemia, and elevated leukocytes as with SCD. However with suspected acute leukemia the WBC count may be significantly elevated to more than 300,000 cells/mcL(ACS, 2020). Also there is no fever, pale appearance, signs of bleedings, or lymphadenopathy which allows me to rule out Leukemia.  Least likely diagnosis: Juvenile idiopathic arthritis formerly known as  Juvenile rheumatoid arthritis is a group of disorders characterized by chronic joint inflammation that appears in children and adolescents before age 16 years (Burns et al., 2016). Common symptoms include, mild to moderate aching , joint stiffness that is worse in the morning and after rest, joint effusion and warmth. Systemic symptoms may include anemia, fever, rheumatoid nodules, leukocytosis and lymphadenopathy. Some patients may have growth abnormalities such as bony overgrowth and limb length discrepancies (Burns et al, 2016).  Rational: Childhood rheumatic inflammatory diseases, such as juvenile idiopathic arthritis (JIA), may begin with similar general symptoms, especially the joint complaints, leukocytosis and anemia. I ruled this diagnosis out because there is no fever,  lymphadenopathy, rash, rheumatoid nodules, warmth over joints or weight loss. Also this condition doesn’t explain the splenomegaly.    Treatment Diagnosis: Additional labs are Hgb electrophoresis and Reticulocyte count levels. Hgb electrophoresis is used to diagnose SCD and the reticulocyte count is used to determine a vaso-occlusive crisis (Burns et al, 2016).  Once SCD diagnosed and a vaso-occlusive crisis is determined, the goal of treatment is pain control with opioid-type medication, IV- rehydration, oxygen therapy to establish near-normal oxygen levels to prevent acidosis and possible vital organ damage (García-Morin et al, 2016). Pain management: NSAIDs or acetaminophen may be adequate for mild to moderate pain, but narcotics should be used when these are not adequate for management . For younger children mild opioids such as codeine is recommended for mild to moderate pain (Sunghee, Brathwaite & Ook, 2017).  Due to his age and uncontrolled pain with current analgesics, I would send him to the ER for further evaluation..  Referral: If positive for SCD, genetic counseling and labs should be offered to the family (Cronin et al.,2018). Management of the child with SCA is complicated and should be done in consultation with a pediatric hematologist (Burns et al., 2016). Education: Parents should be educated about the disease process, importance of regular child wellness exams and immunization, side effects of drugs used for pain management and reassured about the risk of drug addiction when they are used properly. If home management fails, parents are encouraged to call for consultation or a hospital visit (Cronin et al.,2018). References American Cancer Society. (2020). Leukemia in children. Retrieved from https://www.cancer.org/cancer/leukemia-in-children.html (Links to an external site.). Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N. B. & Blosser, C.G. (2016). Pediatric Primary Care (6th ed.). St. Louis, Missouri: Saunders Elsevier Cronin, R. M., Mayo-Gamble, T. L., Stimpson, S.-J., Badawy, S. M., Crosby, L. E., Byrd, J., Volanakis, E. J., Kassim, A. A., Raphael, J. L., Murry, V. M., & DeBaun, M. R. (2018). Adapting medical guidelines to be patient-centered using a patient-driven process for individuals with sickle cell disease and their caregivers. BMC Hematology, 18(1), N.PAG. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1186/s12878-018-0106-3 García-Morin, M., López-Sangüos, C., Vázquez, P., Alvárez, T., Marañón, R., Huerta, J., & Cela, E. (2016). Lactate dehydrogenase: A marker of the severity of vaso-occlusive crisis in children with Sickle Cell Disease presenting at the emergency department. Hemoglobin, 40(6), 388–391. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1080/03630269.2016.1275677 (Links to an external site.) Sunghee, K., Brathwaite, R., & Ook, K. (2017). Evidence-based practice standard care for acute pain management with sickle cell disease in an urgent care center. Quality Management in Health Care, 26(2), 108. o Jennifer Benvin Jennifer Benvin Mar 22, 2020Mar 22 at 7:34pm Manage Discussion Entry Dr. Martin and Classmates,

Summary Post

The patient I presented was an 8-year-old African

American male who was brought in by his mother, who states her son was

complaining of severe joint pain that started two days ago after playing

basketball. Throughout this summary, I will discuss my primary, secondary

diagnosis and wrap it up with a treatment plan for each and summarize my peers’

responses.

The primary diagnosis for this patient would be Juvenile

rheumatoid arthritis

due to the clinical signs the mother and the child

presented with. The clinical signs the patient presented with was joint pain

after was bilateral pain in the knees, elbows, and ankles. JIA is characterized

as stiffness, pain, swelling (Hollier, 2018). JIA can affect the child’s

growth, and development is not caught soon enough and treated adequately

(Hollier, 2018). 

I decided to choose to be Juvenile rheumatoid arthritis based on the complaints the patient had and what the mother presented with to the clinic. The patient has severe joint pain after playing sports and also with movement would lead me to believe he could have this condition.

The treatment plan for this patient would be ordering

blood work such as an ESR) erythrocyte sedimentation to see the rate of the red

blood cells that gather in the bottom of the blood tube once’s drawn (Nordal et

al., 2019). If JIA is detected, the ESR will determine the inflammation (Nordal

et al., 2019). Other blood work that can be ordered would be c-reactive protein

to check for other inflammation that the ESR cannot pick up, and rheumatoid

factors that can identify markers in the child’s blood to check for JRA (Krause

et al., 2017). Besides blood work, imaging scans such as x-rays of the joins at

which are hurting can diagnosis JIA and also stage the disease (Nordal et al.,

2019). Education is critical for children who have JIA, and it is essential to have

the parents teach their children to have a healthy mindset when dealing with

this condition, explaining to the parents that physical therapy can help reduce

painful joints and improve movement (Nordal et al., 2019). Patients who suffer

from JIA can benefit from what is called the federal act 504 that helps

children deal with JIA by offering assistance for school and rehabilitation

(Mendelson et al., 2017).

The secondary diagnosis for this patient could be Sickle Cell Anemia due to the patient experiencing signs and symptoms of pain after playing sports. Due to how sickle cell forms by the red blood cells sticking together, forming a sickle cell shape causes the pain, and when that mother states that her son is in serve pain with moment can lead to my rationale diagnosis of sickle cell disease (DeBaun et al., 2016). The patient also presented with decrease appetite from what the mother stated during the office visit could also indicate this patient to have sickle cell disease (Bernaudin et al., 2016). The patient’s ultrasound reported showed an increased size in the patient’s spleen, which is a common sign for patients with sickle cell disease (Bernaudin et al., 2016).

The treatment plan for this patient is education on preventing any infection that can exacerbate their condition, increase their fluid intake, preferably water, and, if considered, if severe, a blood transfusion to treat anemia (Bernaudin et al., 2016).

Thank you, Alisha, for commenting on my patient case study and I liked how you picked sickle cell anemia as I thought of that soon as I read this case study Dr. Martin provided me. Alisha your other choices were very good, and I did not even think about leukemia for this patient, but all your treatment plans were very well put together.

References

Bernaudin, F., Verlhac, S., Arnaud, C., Kamdem, A., Hau, I., Leveillé, E., ... & Biscardi, S. (2016). Long-term treatment follow-up of children with sickle cell disease monitored with abnormal transcranial Doppler velocities. Blood, The Journal of the American Society of Hematology, 127(14), 1814-1822.

DeBaun, M. R., & Kirkham, F. J. (2016). Central nervous system complications and management in sickle cell disease. Blood, The Journal of the American Society of Hematology, 127(7), 829-838.

Hollier, A. (2018). Clinical guidelines in primary care (2nd ed.). Advanced Practice Educational Association, Inc.

Krause, M. L., Zamora-Legoff, J. A., Crowson, C. S., Muskardin, T. W., Mason, T., & Matteson, E. L. (2017, February). Population-based study of outcomes of patients with juvenile idiopathic arthritis (JIA) compared to non-JIA subjects. In Seminars in arthritis and rheumatism (Vol. 46, No. 4, pp. 439-443). WB Saunders.

Mendelson, A., Rabinowicz, N., Reis, Y., Amarilyo, G., Harel, L., Hashkes, P. J., & Uziel, Y. (2017). Comics as an educational tool for children with juvenile idiopathic arthritis. Pediatric Rheumatology, 15(1), 69.

Nordal, E., Rypdal, V., Arnstad, E. D., Aalto, K., Berntson, L., Ekelund, M., ... & Peltoniemi, S. (2019). Participation in school and physical education in juvenile idiopathic arthritis in a Nordic long-term cohort study. PediatricRheumatology, 17(1),44. • Collapse SubdiscussionAlisha Durm Alisha Durm Mar 18, 2020Mar 18 at 8:15pm Manage Discussion Entry Pediatric Clinical Presentation Patient Information KK, 4 year old, Caucasian, female, NKA , Tanner stage I CC: Pt states “It hurts down there” HPI: Mother presents to the clinic with her 4 yr old daughter who she states is having difficulty sleeping at night. She reports that pt is potty trained but has been wetting the bed lately. She also reports that pt states that “her private part in the front and back is itchy”. Mom states that when she checked she noticed skin irritation and a small white, thin thread-like structure to her peritoneum area.  PMHx: Otitis Media, URI, Immunizations UTD: HepB, DTap, RV, Hib, PCV13, IPV, Influenza, MMR, Varicella, HepA Sx: None Medications: None Social HX: Lives with parents, attends VPK with extended hours M-F from 8am-6pm, has 1 sister & 2 brothers, has a dog, and reports having friends at school. Family Medical HX: Mother & father: No medical HX; Maternal Grandmother: DM, Obesity; Grandfather: HTN. Paternal Grandfather: HTN Grandmother: HTN ROS (Subjective) Constitutional: Denies recent illness, fever or chills. Admits trouble staying asleep Skin: Itching and redness to perineum HEENT: Denies headache, ear pain, congestion or nasal drainage Respiratory: Denies cough, wheezing and SOB Neurological: Denies dizziness Cardiovascular: Denies CP Musculoskeletal: Denies joint pain or stiffness GI: Denies abdominal pain, NVD GU:nocturnal enuresis, denies dysuria and foul odor GYN: Menarche, admits vaginal itching, denies vaginal discharge   Physical Exam (Objective) VS:Vital signs: HR 98, Temp. 98.5, O2: 100% on RA  Weight: 16.4 kg (60th percentile)  Height: 101(50th percentile) BMI 16.1 (72th percentile) Tanner stage I General: Pt appears well nourished and groomed. Dressed age appropriate. No signs of  acute distress. Skin: Clean, dry, intact. Uniform in color. No rashes or lesions. HEENT: Normocephalic, PEARLA, conjunctiva pink and moist, sclera clear, nares patent with no drainage, sinuses non-tender, B/L external ear canals clear  Respiratory: Symmetric chest walls, Lung sounds clear in all lobe. No adventitious lung sounds. Neurological: Alert, speech is clear, recognize parent, responds appropriately Cardiovascular: Regular rate and rhythm, Normal S1 and S2 sounds. Musculoskeletal: Full ROM in all extremities, absence of joint nodules, steady gait Psych:Cooperative, appropriate mood, calm GI: Soft, non-distended, non-tender, normoactive BS in all quadrants. Small thin white thread-like structure on peritoneum. Erythemic excoriation to perineum. GU/GYN: Tanner stage 1, urine yellow and clear, small white thread-like structure to inner labia. o Alisha Durm Alisha Durm Mar 18, 2020Mar 18 at 8:38pm Manage Discussion Entry Labs Urinalysis: WNL Scotch® Tape Test: positive Wet prep: negative clue cells, negative yeast cells  o Collapse SubdiscussionMary Brigid Martin Mary Brigid Martin Mar 19, 2020Mar 19 at 4:05pm Manage Discussion Entry Alisha and class - this CC illuminates patient's words- good job. You wrote:   CC: Pt states “It hurts down there”  Alisha Durm Alisha Durm Mar 22, 2020Mar 22 at 11:40pm Manage Discussion Entry Summary post  KK is a 4 year old caucasian female who presents to the clinic with mother. Her Mom reports chief complaint is that patient states “It hurts down there”.  Mother also reports that her daughter is having difficulty sleeping at night. She reports that although  potty trained, she is wetting the bed. Mom reports that the patient stated that “her private part in the front and back is itchy”. Mom states that when she checked she noticed skin irritation and a small white, thin thread-like structure to her peritoneum area.  The patient's vitals are HR 98, Temp. 98.5, O2: 100% on RA , weight 16.4 kg (60th percentile), height: 101(50th percentile) and BMI 16.1 (72th percentile). She has a past medical history of Otitis Media, URI, and UTD Immunizations. She denies any allergies, medication usage, and surgical history. The patient lives with parents, has 3 siblings, and attends VPK where she has friends. No medical history is reported for parents and a history of DM, HTN and obesity reported for grandparents.  Upon review of systems mom admits that patient is having difficulty sleeping and itching and redness to perineum. She denies fever, chills, recent illness, abdominal pain, vaginal discharge and dysuria. Her physical assessment was unremarkable except for a small white thread-like worm located in peritoneum and vaginal area and erythemic excoriation to perineum. There was an absence of vaginal discharge, abdominal and CVA tenderness. She is in Tanner stage I.   Primary diagnosis: Enterobius vermicularis (Pinworm). Pinworms is a common parasite that lives in the intestine. They are spread by ingesting the eggs that can be found on clothes, sheets, toys, and in stool. The most common clinical presentation of pinworm infection is perianal itching, predominantly occurring at night-time and is caused by the migration of the female pinworm to the anus to lay eggs (Wendt et al., 2019). The most common symptoms include perianal pruritus and problems sleeping. Thin white threadlike adult worms can be seen on undergarments, sheets, clothing, vagina and perianal area  Rational:Cardinal symptoms of a pinworm infection is peri-anal pruritus in which KK has. In addition to symptoms a worm identified macroscopically constitutes evidence of infection. KK also has positive eggs on the tape test. Treatment Diagnosis : For Pinworm diagnosis, visual identification of a worm is sufficent for diagnosis, no additional tests are needed (Wendt et al., 2019).   The CDC (2016) recommends either mebendazole, pyrantel pamoate, or albendazole for the treatment of pinworms. A one time dose is initially given and then another one time dose of the same medication is given 3 weeks later. For best results all family members should be treated (Ahmed & Ahmed, 2018). Education: Take the full course of medication as prescribed, even if they feel better. Advise parents to teach children hygienic precautions such as proper handwashing techniques, avoid putting hands in mouth, and thoroughly washing fruits and vegetables to minimize reinfection. Advise parents to sanitize toilets daily and wash (do not shake) all bedding, undergarments, towels, and nightclothes after treated (Jawad., Adai, & Hussein, 2018). Secondary diagnosis: Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning (Paladine & Desai, 2018)..  Common symptoms include vaginal discharge, erythema, soreness, pruritus,  and dysuria. Rational:  Vaginitis is the most common gynecological complication in prepubertal girls and may due to nonspecific etiology. KK’s urine and vaginal swab was negative with allowed me to rule out candida and bacterial causes.  Treatment of noninfectious vaginitis should be directed at the underlying cause such as removal of irritants. Educate parents to avoid the use of scented detergents, soaps, dryer sheets and wipes. Teach parents to  avoid nylons, tight fitting clothes, and non cotton underwear. (Laufer & Emans, 2019). References Ahmed, M., Ali, M. A., & Ahmad, Z. (2017). Extra-Intestinal Isolation of Enterobius Vermicularis. Pediatric Oncall Journal, 14(1), 19. https://doi-org.chamberlainuniversity.idm.oclc.org/10.7199/ped.oncall.2017.5 (Links to an external site.) Centers for Disease Control and Prevention.(2016). Enterobiasis (Enteroblus vermicularis). Retrieved on March 22, 2020 from https://www.cdc.gov/dpdx/enterobiasis/index.html  Jawad, M. K., Adai, M., & Hussein, Z. A. (2018). Education program to improve mother’s knowledge about management of children with pinworms. Indian Journal of Public Health Research & Development, 9(10), 703–707. https://doi-org.chamberlainuniversity.idm.oclc.org/10.5958/0976-5506.2018.01218.4 (Links to an external site.) Laufer, M. & Emans, J. (2019). Overview of vulvovaginal complaints in the prepubertal child. Uptodate. Retrieved March 22, 2020, from https://www.uptodate.com/contents/overview-of-vulvovaginal-complaints-in-the-prepubertal-child?search=vaginal%20yeast%20infection%20children&source=search_result&selectedTitle=1~68&usage_type=default&display_rank=1 (Links to an external site.) Paladine, H. L., & Desai, U. A. (2018). Vaginitis: Diagnosis and treatment. American Family Physician, 97(5),321–329.https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=29671516&site=eds-live&scope=site (Links to an external site.) Wendt, S., Trawinski, H., Schubert, S., Rodloff, A. C., Mössner, J., & Lübbert, C. (2019). The Diagnosis and Treatment of Pinworm Infection. Deutsches Aerzteblatt International, 116(13), 213–219. https://doiorg.chamberlainuniversity.idm.oclc.org/10.3238/arztebl.2019.0213 o Mary Brigid Martin Mary Brigid Martin Mar 21, 2020Mar 21 at 5:57pm Manage Discussion Entry Good job Alicia -please describe what you would see at Tanner stage one for this patient. o Collapse SubdiscussionLiz Cannon Liz Cannon Mar 22, 2020Mar 22 at 6:40pm Manage Discussion Entry Good Evening Alisha, Very interesting case. For this peer review our response must include our top three differentials based on the information provided and rationale for our choices based on the presentation findings. Pertinent positives include the following: Difficulty sleeping at night, recent bed wetting despite being potty trained, complaint from the child that “her private part in the front and back is itchy,” skin irritation and a small white, thin thread-like structure to her peritoneum area. ROS: troubling staying asleep, itching and redness to perineum, nocturnal enuresis and vaginal itching. Objective: small thin white thread-like structure on peritoneum, erythemic excoriation to perineum My top three differentials: Pinworms The reason for the diagnosis of pinworms is based on her complaints of itching with irritation in her perineal area, difficulty sleeping at night and new onset of nocturnal enuresis. This diagnosis is also supported by the finding of a small thin white thread-like structure on the peritoneum and a positive Scotch Tape Test. Scabies The reason for scabies as a possible differential is due to complaint of itching in her private area, skin irritation with redness and erythemic excoriation to perineum.   Vaginitis This differential was chosen as a possibility due to the presence of itching and erythema in the perineum.   The primary diagnosis I am leaning towards is Pinworms. Treatment for pinworms takes into consideration its mode of transmission which includes from fingernails or on clothing, bedding, toilets, doorknobs and food. The Centers for Disease Control and Prevention (CDC), (2019), indicates the drugs of choice for treatment of pinworms include mebendazole, albendazole, or pyrantel pamoate. Whichever of these is chosen is provided to the patient and family as an initial single dose followed by another dose of the same drug 2 weeks later. This second dose is to eliminate reinfection post first dose and some medications, like Pyrantel pamoate is available without prescription (CDC, 2019).   References: Centers for Disease Control and Prevention. (2016). Parasites-Enterobiasis (Treatment). Retrieved from https://www.cdc.gov/parasites/pinworm/treatment.html (Links to an external site.).  Alisha Durm Alisha Durm Mar 22, 2020Mar 22 at 11:41pm Manage Discussion Entry Thank you Liz , You were correct. Pinworms is the primary diagnosis.  • Collapse SubdiscussionDavid Valdes David Valdes Mar 18, 2020Mar 18 at 11:16pm Manage Discussion Entry Dr. Martin and class,   Subjective:   (Patient Information): S.S., 17-year old female, Hispanic (CC): Coughing and feeling fatigued (HPI): The patient states that she began having a dry cough that began 1 year ago and feeling occasionally fatigued that began 6 months ago. The patient states that her chest sometimes feels tight and has been coughing most days, especially during the nighttime but not daily. The patient states that she is also feeling tired and stressed. (Allergies): Pollen (Current Medications): None (PMHX): Denies any hospitalizations, no flu vaccination done, and childhood immunizations up to date. (Social Hx): Lives in a rental home with her parents and two younger siblings. (Family History): Father smokes tobacco (ROS): Constitutional: Headaches, fatigue, denies weight loss or fever HEENT: Rhinorrhea, denies epistaxis, denies a sore throat or tinnitus Respiratory: Occasional wheezing, dry cough Cardiovascular: Chest tightness, shortness of breath Psych: Anxiety   Objective:   Constitutional: B/P 124/80, RR 14, Temp 98.4, Height 161 cm, Weight 32kg, BMI 27, 89th percentile, tanner 5   Body Systems (Positive Findings):  HEENT: Pales nasal mucosa and clear nasal discharge Respiratory: Prolonged expiratory phase   Body Systems (Negative Findings): General: AAO x 3, skin moist and warm HEENT: Oropharynx pink, uvula pink, TM pearly gray, no nasal polyps, no sinus tenderness, no neck lymphadenopathy. Respiratory: lung sounds clear, chest symmetrical, no retractions noted, and unlabored respirations Cardiovascular: S1/S2 noted, RRR, and no murmurs noted   Labs: CBC, CMP, and PFT pending.   o Samantha Bouie Samantha Bouie Mar 19, 2020Mar 19 at 5:12pm Manage Discussion Entry Hi David! Thank you for your interesting case! My top three differentials are as follows: 0. Asthma--Pertinent findings that support this diagnosis includes persistent cough that started a year ago, wheezing lung sounds, fatigue, occasional wheezing, chest tightness and prolonged expiratory phase. There is great significance in the prolonged expiratory phase finding. This finding combined with wheezing is very telling. For the asthmatic patient, accessory muscles are commonly used to expel air, due to airway constriction, which causes the prolonged expiratory phase. Wheezing, chest tightness and shortness of breath are also symptoms commonly associated with asthma.  1. Chronic Bronchitis--Pertinent findings that support this diagnosis includes cough lasting greater than 6 months, shortness of breath, occasional wheezing and chest tightness. It is also noted that the patient has been exposed to tobacco smoke in the home, her father smokes tobacco. Constant exposure to second-hand smoking over time, can cause inflammation and damage to respiratory structures, placing the patient at high risk for chronic bronchitis.  2. Allergic Rhinitis--Pertinent findings that support this diagnosis includes rhinorrhea, clear nasal drainage. It's important to take into account that the patient does have history of allergy to pollen. Seasonal allergies can cause coughing and rhinorrhea.  The primary diagnosis I am leaning toward would definitely be asthma. The patient's current presentation mirrors the clinical presentation for asthma. She is wheezing occasionally, experiencing chest tightness, has a chronic cough, shortness of breath and also has prolonged expiratory phase. It's important to use an individualized approach when treating asthma. Considering factors such as severity of symptoms and whether or not asthmatic episodes are triggered by exercise or allergies, plays an important role in the patient's response to treatment (Falk, Hughes, & Rodgers, 2016). In this patient's case, it's imperative to acknowledge her exposure to tobacco smoke in her home, her fatigue and chronic cough, as well as her allergies to pollen. Spirometry testing is commonly used for confirming a diagnosis. Treatment should never begin without spirometry testing first. It's important to regard whether or not her asthma is mild, moderate, or severe, as this will also affect approach to treatment. The patient in this case falls under the “moderate” category because she is experiencing daily symptoms.She may benefit from an inhaled corticosteroid such as Flovent to be used daily, and a short acting beta-agonist (SABA) inhaler such as albuterol to be used as needed for shortness of breath (Falk, Hughes, & Rodgers, 2016). I would also ask her to begin keeping an “asthma diary” to help identify trends and possible triggers. Close follow-up is needed to evaluate response to therapy and possible need for changes to the regimine. I would also use a family centered approach and discuss the need of smoking cessation with her father, and emphasize that this is not only for her health benefit, but for his as well. Thank you Samantha Bouie References Falk, N., Hughes, S., & Rodgers, B. (2016). Medications for chronic asthma. American Family Physician, 94(6):454-462. Retrieved from www.aafp.org. o Shamma Chery Shamma Chery Mar 19, 2020Mar 19 at 11:08pm Manage Discussion Entry Great case study David  Primary Differential Diagnosis: Asthma Asthma is a common disease, characterized by variable airflow obstruction and airway inflammation that leads to symptoms of breathlessness, wheezing, chest tightness and cough (Kavanagh, Jackson, & Kent, 2019). Other signs and symptoms include nocturnal awakening, rhinorrhea, and intercostal retractions. I chose this diagnosis as the main differential because the patient present with most of the symptoms.  pertinent positives: (+) persistent cough,  wheezes, (+) SOB with exertion, (+) rhinorrhea, (+) mild  pertinent negatives: (-) tightness in chest Treatment: Treatment for asthma depends on the classification. Since this is a new occurrence I would classify as intermittent asthma and treat with a short-acting beta2-agonist and if symptoms persists then a low-dose inhaled corticosteroid would be added for better control (National Heart, Lung, and Blood Institute, 2018). Also the patient needs to go back on the medications he stopped taking and with the parents we need to come up with an asthma action plan.   Differential #2: Viral rhinitis (Common Cold) Viral rhinitis is also known as the common cold. It involves sneezing, coughing, congested or runny nose, sore throat and is similar to allergic rhinitis but presents a little bit differently (Ramakrishnan & Cooper, 2017). Even if  patient denied fever  I think viral rhinitis is also a good differential. pertinent positives: (+) sore throat, (+) cough, (+) fever, (+) throat erythema, (+) fatigue, (+) rhinorrhea pertinent negatives: (-) headache, (-) sneezing   Differential #3: Allergic rhinitis Allergic rhinitis is an immunoglobulin E-mediated condition that happens after exposure to indoor or outdoor allergens (Sur & Plesa, 2015). Allergens can included dust mites, insects, pollen, molds, and pet dander. Symptoms include sneezing, rhinorrhea, watery, itchy eyes, congestion, sore throat, puffy eyes, headache, and shortness of breath. The patient could have allergic rhinitis based on his history . pertinent positives: , (+) cough, (+) hx ,   watery rhinorrhea pertinent negatives: (-)sneezing, (-) itchy nose, (-) headache   Thanks,   References: Kavanagh, J., Jackson, D. J., & Kent, B. D. (2019). Over- and under- diagnosis in asthma. Breathe, 15(1), 110-117. doi:10.1183/20734735.0362-2018 National Heart, Lung, and Blood Institute (NHLBI). (2018). Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf Ramakrishnan, V. R., & Cooper, S. (2017). Pharmacotherapy for nonallergic rhinitis. Retrieved from http://emedicine.medscape.com/article/874171-overview(GI) o David Valdes David Valdes Mar 22, 2020Mar 22 at 10:19am Manage Discussion Entry Dr. Martin and class,   Summary Post               The presented patient is a 17-year-old Hispanic female complaining of coughing and feeling fatigued. A primary and secondary differential diagnosis was formulated for the presented patient and treatment plans will be further discussed for each selected diagnosis.   Primary Diagnosis: Asthma             Asthma is a chronic lung disease that affects the lungs by narrowing airways (Lambrecht and Hammad, 2019). Pertinent findings that were presented in the case were that the patient was complaining of a constant cough for the past year, having chest tightness, shortness of breath, wheezing, and a cough that worsened at night. Upon assessment, the patient’s lung sounds were clear, and she had unlabored respirations. Either smoking cigarettes or being exposed to cigarette smoke is an asthma trigger that can exacerbate an asthma attack (Hollier, 2016). The patient’s father smokes tobacco which puts her at a higher risk of triggering an asthma attack.             A treatment plan was developed to assist in providing care for the presented patient. To begin with, medications that include short-acting bronchodilators, asthma exacerbations, inhaled corticosteroids, and leukotrienes can be prescribed to the patient to help manage her asthma (Lambrecht and Hammad, 2019). Spirometry testing can be performed to help determine the severity of the patient’s asthma (Hollier, 2016). Educating both the patient and her family on asthma exacerbation triggers and non-pharmacological interventions can assist in properly managing her asthma. The healthcare provider can discuss preventative measures and nonpharmacological interventions that include avoiding asthma triggers, educating her father to stop smoking, developing an asthma action plan, and monitoring peak flow values (Hollier, 2016).   Secondary Diagnosis: Bronchitis             Bronchitis is the inflammation of the bronchioles and an excess of mucus production limiting airflow (Centers for Disease and Prevention, 2019). The patient stated that she had a cough that has lasted for a year, has been experiencing wheezing and has been having chest tightness. Cigarette smoke is a risk factor for developing either acute or chronic bronchitis (Pahwa et al., 2017). The patient’s father smokes cigarettes which also increases the patient’s risk of developing bronchitis. The healthcare provider can provide care for this patient and promote positive health outcomes.             A treatment plan can be implemented to help treat a patient who has developed bronchitis. Nonpharmacological measures include advising the patient to stay properly hydrated, emphasis on the importance of adequate rest, smoking cessation, and the utilization of humidified air (Hollier, 2016). It is imperative to educate the patient’s father on the negative effects of exposing his daughter to secondhand smoke and develop a plan to no longer expose her to cigarettes. Short-acting bronchodilators, long-acting bronchodilators, anticholinergics, inhaled corticosteroids, and combination inhaled corticosteroids are medication that can be utilized in treating bronchitis (Saleem et al., 2018).  Through the implementation of a well-developed treatment plan and effective communication among the healthcare provider and both the patient and family, positive health outcomes can be achieved.             This week’s discussion thread allowed both students and the professor to formulate an interactive conversation on each student’s presented patient. Two fellow students both replied to my initial post providing incite and formulating differential diagnoses for the patient. Samantha’s three differential diagnoses were asthma, chronic bronchitis, and allergic rhinitis while selecting asthma as her primary diagnosis. Shamma’s three differential diagnoses were asthma, viral rhinitis, and allergic rhinitis while also selecting asthma as her primary diagnosis. They both formulated treatment plans that can be implemented into the overall care that this patient would receive.     References   Centers for Disease Control and Prevention. (2019). Acute bronchitis.      https://www.cdc.gov/antibiotic-use/community/for-patients/common-      illnesses/bronchitis.html Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Advanced Practice      Educational Association, Inc. Lambrecht, B. N., Hammad, H., & Fahy, J. V. (2019). The cytokines of asthma. Immunity, 50(4),      975-991. https://www.sciencedirect.com/science/article/abs/pii/S1074761319301359 Pahwa, P., Karunanayake, C. P., Rennie, D. C., Lawson, J. A., Ramsden, V. R., McMullin, K., &      Dosman, J. A. (2017). Prevalence and associated risk factors of chronic bronchitis in first      nations people. BMC pulmonary medicine, 17(1), 1-10.https://bmcpulmmed.biomed  (Links to an external site.)      central.com/a (Links to an external site.)rticles/10.1186/s12890-017-0432-4 Saleem, S., Sardar, K., & Javed, N. (2018). Chronic bronchitis. Professional Medical Journal,      25(8),1240-1244. https://web-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/e (Links to an external site.)      host/pdfviewer/p dfviewer ?vid=1&sid=9f33368d-efd5-4346-bf98-      c614698a344c%40sdc-v-sessmgr02 - - - - - - - - - - - - - - - - - - - - - - - - - - Shamma Chery Shamma Chery Mar 22, 2020Mar 22 at 12:33pm Manage Discussion Entry Professor Class  and class, I am so happy that both my classmates  were able to correctly diagnose my patient, even though we threw a curveball in with some of his nonrelated symptoms. Rhinosinusitis, or more commonly sinusitis, is the medical term for inflammation of the lining of the sinuses and nose. There are two main types of sinusitis: acute and chronic. Acute sinusitis is inflammation that lasts for less than 4 weeks, subacute sinusitis lasts from 4 to 12 weeks, while chronic sinusitis lasts for more than 12 weeks. Acute sinusitis is common (Patel, 2018). As far as a Primary Diagnoses, we diagnosed him with acute sinusitis [ICD-10: J01.90]. His Secondary Diagnosis included dysfunction of both eustachian tubes [ICD-10: H69.93] and localized enlarged lymph nodes R59.0. In order to diagnose this patient with sinusitis, we had to just use physical assessment, his complaints, and our critical thinking skills. For treatment, we prescribed Augmentin 875-125 MG Oral Tablet for sinus infection, Take 1 tablet (875 mg) by mouth every 12 hours for 10 days, Dispense # 20 tablets, Refills: 0. Since we weren't a hundred percent sure why this patient had dependent edema and swollen lymph nodes in his groin, we didn't prescribe any medications for that, but we did refer to someone who can figure out what was going on there. Education included rest, increase fluids, Claritin am, Benadryl pm, Motrin for comfort, change toothbrush in 3 days, salt water gargles, good handwashing, do not share cups, utensils, straws, or anything by mouth, etc., yogurt or probiotics while on antibiotic therapy, note provided for work and scanned into chart. Activity included rest and activity as tolerated. As far as referrals, for sinusitis, we don't typically refer unless the sinusitis is recurrent. Then we might refer to ENT for further evaluation for frequent infections. For this case, referrals included following up with his PCP Pediatric Healthcare Alliance and schedule well check if not already completed this year. We also recommended to follow up with urology to make sure not testicular cause to swollen lymph. As far as follow up goes, if symptoms are no better, or there are worsening of symptoms instructed to seek medical attention, or go to the emergency room. Access to patient portal and education provided. Follow up 48 hours.Thank you so much class for all of your input. You all did such a great job this week!   References Patel, Z., & Hwang, P. (2018, February). Acute sinusitis (sinus infection) (Beyond the Basics). Retrieved from https://www.uptodate.com/contents/acute-sinusitis-sinus-infection-beyond-the-basics PreviousNext [Show More]

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