06 Feb Neck: Denies lumps, pain, stiffness
MSN610 Diagnostic Reasoning and Advanced Physical Assessment
Module 2 Discussion
Case Study 2A
C.C. M.A. is a 6 year old female who presents for a sick episodic visit who is accompanied with her mother for sore throat, fever and rash.
HPI: Her mother states M.A.. has been sick for about 4 days which started with a headache. Then she developed a sore throat and runny nose. M.A.. now appears feverish and doesn’t feel like eating much.
She normally attends pre-school, but mom has kept her home yesterday and today since she felt feverish. Now, this morning, she has this rash. The rash is “a little itchy”. Mom denies changing laundry detergents, foods, soaps and there has been no known exposure to anyone else with a rash or illness.
M.A. has never had a rash previously.
PMH: Growth percentiles within normal limits on previous visits
Immunizations Record:
DPT given at: 2 mos 4mos 6 mos 18 mos 5 yr
OPV given at: 2 mos 4 mos 18 mos 5 yr
MMR: given at: 13 mos 5 yr
Hib given at: 2 mos 4 mos 6 mos 18 mos
FH:
Relationship Mortality Age Health Problems Relationship Mortality Age Health Problems
Mother Alive 27 None Father Alive 27 None
MGM Alive 51 HTN/DM MGF Alive 48 HLN
PGM Alive 45 None PGF Alive 52 Prostate CA
SH: Lives with mother but spends every other weekend with father who lives in a suburban area 15 miles away. Mother is an elementary school teacher and Father is an social worker. Parents have been divorced for 2 years. M.A. is doing well in the first grade without social or behavioral problems.
Meds: Children’s Tylenol 1 dose last pm Allergies: None
ROS:
General: Mom denies weight loss, fatigue until the last 3 days, generally eats well
Skin: Mom denies birthmarks, scars, no previous rashes
HEENT: Denies dizziness, head trauma, vision trouble, does not wear glasses, has about 3 colds/year, denies swallowing problems, nasal congestion, Admits to sore throat, difficulty swallowing, but drinking fluids as normal
Neck: Denies lumps, pain, stiffness
Resp: Denies dyspnea or pain, admits to rare non-productive cough for 48 hours
Cardiac: Denies chest pain, irregular heart rate, or edema
Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain
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