10 y/o child w/ cough, expiratory wheezing, runny nose, watery eyes, tonsils 2+, drainage.

[Sandrion]

I am working on this case study, I think I have an idea of the diagnosis but I have doubt> As for my 3 differential diagnoses, I come up with: Asthma, chronic sinusitis, and allergic disease/post nasal drip.

Please, I am not looking for someone to answer the question but rather starting a discussion that can help me figure out if I am in the right direction.

Question 1.

Introduction: O.A. is a 10-year-old who presents to the clinic in the care of his mother (MOC). She states that he has been sick since school started (it is now November) and she thinks he has a sinus infection. The family is established with the clinic and do come in regularly for primary health care.

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[TD=colspan: 4]Chief Complaint

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[TD=colspan: 4]"He has a sinus infection or something."

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[TD=colspan: 4]History of Present Illness

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[TD=colspan: 4]O.A. is a 10-year-old who presents to the clinic in the care of his mother with a complaint of runny nose, sneezing, watery eye, and a dry cough. He has not had a fever with this illness. MOC states that he has been mildly ill since school started 3 months ago but he has "gotten worse" in the past week. The patient denies ear pain, sore throat, or headache. He has not had any vomiting or diarrhea. He has missed one day of school in the past week due to illness.

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[TD=colspan: 4]Past Medical History

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[TD=colspan: 4]Negative for chronic health problems.

There are no known allergies to medications.

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[TD=colspan: 2]Past Surgical History

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[TD=colspan: 4]Inguinal hernia repair age 18 months

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[TD=colspan: 2]Family History

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[TD=colspan: 4]· Father alive and well; history of asthma and eczema.

· Mother alive and well; history of seasonal allergies and gestational diabetes..

· One brother age 8 years, alive and well.

· No other family members have a significant medical history.

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[TD=colspan: 4]Social History

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[TD=colspan: 4]· Lives with family in rented home in suburb.

· No exposures to passive smoke.

· 5^th grader, doing well in school

· Loves all kinds of sports.

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[TD=colspan: 4]Current Medications

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[TD=colspan: 4]None

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[TD=colspan: 4]Physical Examination

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[TD]BP=100/68

P=100 and regular

RR=16

SaO₂=99%

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[TD=colspan: 2]T= 97.5^O F/36.4^O C

Height 58 inches

Weight 78 pounds

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[TD]General

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[TD=colspan: 3]Alert, well groomed; in no acute distress

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[TD]HEENT

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[TD=colspan: 3]Head: Normocephalic, atraumatic; scalp clear

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[TD=colspan: 3]Eyes: clear, PERLA

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[TD=colspan: 3]Ears: TMs pearly, positive light reflexes; canals clear; few fluid bubbles visible behind TMs

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[TD=colspan: 3]Nose: moderate amount clear discharge bilaterally

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[TD=colspan: 3]Throat: mildly erythematous, tonsils 2+, uvula midline. Discharge noted in posterior pharynx.

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[TD]Neck

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[TD=colspan: 3]Supple, full range of motion; no lymphadenopathy

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[TD]Chest

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[TD=colspan: 3]Symmetric, easy respirations bilaterally

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[TD]Lungs

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[TD=colspan: 3]Equal, mild decrease in air entry in bilateral bases; occasional expiratory wheeze. Occasional dry cough.

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[TD]Cardiac

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[TD=colspan: 3]Normal S1/S2, no murmurs heard

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[TD]Abdomen

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[TD=colspan: 3]Non-distended, non-tender. Positive BS x 4

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[TD]MSK

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[TD=colspan: 3]Moves all extremities with full ROM; climbs onto exam table easily.

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[TD]Neuro

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[TD=colspan: 3]A & O x 3; cranial nerves II-XII intact. Sensory and motor nerves intact, DTRs 2+, (-) Babinski

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[TD]Skin

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[TD=colspan: 3]Warm and dry; erythematous, scaling patches in antecubital spaces.

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Question 1)

What other questions would you have for O.A. and his mother at this point?

Question 2.

Given the information about O.A. at this time, what are some likely reasons for the symptoms he is having? Provide list of 3 differential diagnoses (no more than 3).

Question 3.

In order to provide a thorough health assessment of O.A, what diagnostic tests (if any) would you order for him at this time? What diagnostic tests would you order in the future?

Identify what tests you are ordering at this visit vs those that are for the future.

Be definitive as this is your order section. Avoid words like "should, could, may, etc."

Question 4.

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[TD=colspan: 3]Other Diagnostics

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[TD]Office Spirometry:

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[TD]· FEV1 >80 percent predicted

· FEV1/FVC >85 percent

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[TD]Peak Flows=300, 210, 190

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4) In reviewing the findings from his physical examination and diagnostic workup, which results are abnormal?

Question 5.

Of the problems identified for this patient, which is the most concerning and therefore is your primary dx for this visit?

Question 6.

Thoroughly explain the pathophysiology for each of the 3 differential diagnoses identified for this patient. What key information would you want to be sure to share with this patient and his mother?

Question 7.

What are the 5 primary goals/outcomes to include in a comprehensive plan of care for this patient?

Question 8.

Outline a comprehensive plan for this patient. Include information related to diet, exercise, medications, additional diagnostic evaluations, and follow-up appointments. Be concise using bullets for each element of your plan. These are orders so be definitive, again avoiding words like "should, would, could, consider, etc."

Question 9.

In working with this patient, what health consequences would you want to discuss with him and his mother if he chooses to not to engage in the plan you outlined for him?

[Rose_Queen, BSN, MSN, RN]

In order to have a discussion, you must start it. What are your thoughts on all of those questions?

[Sandrion]

Pt's father has a history of asthma and eczema. Mother has history of seasonal allergies.

Pt presents w/ c/o runny nose, sneezing, watery eye, and a dry cough. No hx of fever w/ the illness, pt's has been sick for 3 months but things are getting worst now. Pt denies N/D, ear pain, sore throat, or headache.......

Possible differential diagnoses: Asthma (family hx), sinusitis, post nasal drainage.

But I have many questions for the parent & son:

What time of the day is the cough worst?

Has the patient experienced a reduced sense of taste or smell, general malaise/fatigue, facial pressure, thick green or yellow mucus?

Is it difficult for him to breathe through his nose?

Any facial pain or tenderness?

Am I wrong so far?