Case Studies: 5-year-old male Informant: Mrs. Lovely Child: 5 year old Reily (male) Day/Time: Monday; 10 amCC: 5-year-old male presents with mother for well child visit & follow up From ER visit this weekend for asthma and fever Interim HistoryHas been doing well since last visit with one or two mild episodes asthma – which were controlled at home with albuterol nebulizations/pump until this Saturday when he developed a fever and cough and became short of breath even after 4 nebulizer treatments at home, at 2 pm on Saturday he was noted to have a fever of 101.2 and had a febrile seizure which consisted of tonic/clonic movements of all extremities and lasted a few minutes. He was taken to the ER where he was evaluated; received 3 more treatments and one dose of prednisone and was d/c’d home with diagnosis of URI and Asthma. Since Saturday he continues to cough and wheeze and is taking albuterol nebs q 4 hours as well as his prednisone as ordered. He last had a temperature of 100.9 this morning. Past Medical History: Prenatal/Natal:Born at 39 weeks to a 41 year old G1 P0000 via C-section due to failure to progress; conceived via IVF after 3 years of infertility medications with no resultsBirth Weight: 3.9 kgPrenatal care started @ conceptionNo complications with deliveryD/c’d on day of life #2 Neonatal: Breast-fed exclusively till 6 months of age- began juices and baby food + Bronchiolitis at age 4 months – admitted for 2 days for monitoring Illnesses:+ Asthma- diagnosed @ about 2 years of age, + admission for asthma @ 2 years no ICU admissions; no intubations, + history of steroids- last one prior to now 6 months; 1 OM at 8 months of age; + history of febrile seizures since 1 year of age- has had 3 febrile seizures since thenEczema Accidents: + nursemaid’s elbow @ 10 months of age Hospitalizations: As above for Bronchiolitis/asthmaImmunizations: as per mom- will bring documentation next visit Allergies: Amoxicillin (rash)Medications: Albuterol nebs q 4-6 hours prn Albuterol pump q 6 hours prn with spacer Prednisone 60 mg once a day (on day 3/5) Nutrition:Described as “good eater”; eats almost anything that the family eats: 24 hour recall: breakfast: bowl of cherrios, sliced apples; pop tart Snack: pretzels, and soda Lunch: grilled cheese sandwich; glass of whole milk Snack: Brownies Dinner: raviolis and peas, milk; ice cream &sugar cookies for desert Social/Environmental lives in suburban upper-middle class neighborhoodHouse was built in 1960’s; 4 bedrooms with large backyard on a lake, lives with mother, father and family dog; father + smoker- but not in house- only out on patio; park is nearby, no rodents or peeling paint; grandparents live 2 hours away and visit once a month Activity:Very active as per mom; lives to play outside, watches about 1 hour of TV a night; uses computer prior to going to bed; has a group of friends from neighborhood ranging from 3 ½ to 5 years old; recently registered to start cyo soccer camp in summer (2 months from now) Sleep: sleeps in bed with his favorite toy “Thomas the train” (stuffed) Sleeps from about 8:30 pm to 7 amMay fall asleep sometimes in afternoon when he’s been outside a lot in the morning Elimination: Bladder trained 3 yrs 2 months- but has always had occasional accidents- used to be during day when playing, for past year has about 4 episodes per month of wetting bed at night, mom is concerned because he is now asking to have sleep over at his friend’s house but she is worried if he wets the bed it will embarrass him Bowel trained: @ 3 ½ years of age; denies problems with constipation: has regular BM q other day in morning Growth and Development: Smiled @ 3 weeks Sat @ 8 months Walked @ 15 months Drank from cup @ 18 months First intelligible words @ 20 months Speech is 90% intelligible to strangers- still has trouble with “L’s” Recently started stuttering at school Can dress self with help for buttons and zippers, does not ties shoesJumps hops & skipsCan draw circle and cross & squareDraws person with 2 parts (demonstrated)Difficulty with heel-toe walkCan balance on one foot for 10 secondsJumps, and skips ROS: General: mom describes him as an alert, happy active 5-year-old who recently began to stutter occasionally when he is upset or excited, loves to run and play; over past few days with fever has seemed a bit more tired but is still playful at timesSkin hx of eczema but mom denies any current active rashes HEENT: Head: denies any headache, no history of head trauma or injuryEyes: + red eyes with recent illness and itching a lot ; vision testing was done in preschool- as per mom (not totally sure)Ears: No c/o ear pain, no ear d/c, cleans ears with q-tip and hydrogen peroxide after each bathNose for past 2 days + green rhinorhea + snoring with sleeping over past few days Throat c/o sore throat since yesterday, able to swallow, brushes teeth by himself; + sucks his thumb to fall asleep; no dental carries thus far- one visit to dentist 6 months ago Chest: + history of cough for past few days and with colds and asthma; has been taking asthma meds as previously stated, took Robitussin last pm due to coughing and congestion interrupting his sleep; no shortness of breath today, + mild coughing improves after treatments, + one episode on Saturday of post tussive vomiting, none since then; no history of heart murmur or chest pain Abdomen: + one episode on Saturday of c/o abdominal pain before episode of post-tussive vomiting; no diarrhea, decreased po intake of food but takes juices/water well GU + urine output, no dysuria, no frequency MS likes to run; play; no complaints of muscle/joint pain, climbs well Neuro: started to stutter about 2 months age- worse when he is frustrated; excited or upset; no other changes in language; alert and active as per mom Physical Exam: Temp 100.8 po HR 110 RR 28 Wt: 32 kg Ht 116 cm General: alert 5 year old mildly ill appearing; playing with toy car on tableSkin 2 cm x 2 cm circular area of hair loss with scaly appearance to posterior occipital region of scalp;HEENT: Head NCAT, symmetrical faciesEyes: conjunctiva pink with sclera injection, + clear d/c, PERRLA; disc margins sharp; no papiledema, EOMI, vision: OU 20/30; OS 20/30 OD 20/30; Ears: Bilateral TM’s pearl grey; + light reflex bilaterally; + landmarks; + small effusion noted to upper aspect of L TM; + mobility bilaterally; hearing test unable to be completed- machine broken Nose: nares patent, small amount crusted green rhinorhea noted to bilateral nares; turbinates: erythematous and slightly hypertrophiedThroat/Mouth: posterior pharynx erythematous, tonsils +2 with no exudate or petechiae; uvula midline, teeth without dentition noted; + mucous membranes moist Chest: Lungs with end expiratory wheezing noted bilaterally with slightly decreased air entry to bilateral lower lobes; no retractions, no nasal flaring, no rales Heart Heart rate regular, S1 and S2 audible, no murmur ausculated Abdomen: protuberant, soft + bowel sounds, no masses, no pain with palpation, no HSM, no CVA tenderness GU: Testes descended bilaterally, circumcised penis with urethra midline, Tanner I MS: walks well, spine symmetrical with no dimples/hair tufts; jumps on 2 feet but cannot hop on one foot; skips, full ROM of all extremities; no swelling to extremities; Neuro Alert; speech clear with occasional words difficult to decipher; occasional stutter noted; alert and oriented to person and place, reflexes +2 to all extremities; balance normal; gait normal; muscle strength 5/5 bilaterally Working up the differentials & treatment for each differential Physical examConcerns? DiagnosesLabs/testsTreatment plan for diagnosisMedicationsEducationreferrals Well Child VisitImmunizationsTo be given todayScreening/testsTo be done based on this visit Anticipatory guidance Developmental assessment Is infant meeting milestoneSocial & emotionalLanguageCognitiveGross motor/fine motorNutritionSleepEliminationSafety/injurySocial Determinants of healthReferralsFollow up visits Health Science Science NursingNURS 775
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