27 Dec Diagnostic Reasoning and Advanced

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

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 3 Discussion

Diagnostic Reasoning and Advanced Physical Assessment

MODULE 3 CASE STUDY

BJ is a 10 yr old female of Hispanic origin who presents to your exam room with an adult Hispanic male that identifies himself as her uncle. He states that BJ has hurt her Right arm after falling down the steps the day before. He states she did NOT loss consciousness or injury her head. The providers asks BJ, “How did you fall down the steps?” BJ looks down and softly states, “I just tripped and feel:. Both speak with broken English.

PMI: No hospitalization or Surgeries. Immunization History is unknown.

Medications: None Allergies: None

FH: Parents Living Mother age 24 Father age 30, No Siblings

SH: Both parents work cleaning in the hotel industry. BJ is “home schooled” by her aunt.

ROS:

General: NEG weight loss or gain NEG fatigue, NEG fever

HEENT: NEG for headache, congestion, nasal drainage, vision problems, throat pain

Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness

Resp: NEG Dyspnea, Neg for cough, wheezing, NEG PND

GI: NEG Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia

MS: + R Shoulder Joint pain, +Joint Swelling, + for falls

HEME: + for bruising NEG for bleeding, Neg night sweats

ENDO: Neg for thirst, heat or cold intolerance

NEURO: NEG dizziness, Neg for confusion, numbness, aphasia

PSYCH: NEG for memory loss, Neg for nervousness, suicidal ideation