COMPREHESIVE CASE STUDY WEEK #4 (CLASS 6541) REASON FOR ENCOUNTER ; COUGH ….. 18 MONTHS, Exams of Health sciences

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COMPREHESIVE CASE STUDY WEEK #4 (CLASS 6541) REASON

FOR ENCOUNTER ; COUGH ….. 18 MONTHS OLD PATIENT

TESTING AND TREATMENT ,AND FOLLOW UP CARE LATEST

2024 - 2025 ACTUAL SCREENSHOT.

Patient Information:

• Age: 18 months
• Height: 2'11" (89 cm)
• Weight: 28.0 lb (12.7 kg)
• Reason for Encounter: Cough

C: 18 y/o M Chief complaint is a short 1-2 statement or word phrase from patient and should be listed in “quotes” “I feel awful, I’m exhausted. I have body aches and just feel really tired.”

HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts 18 month, an 18-yr-old male presented to the clinic with co persistent dry cough, sore throat, right ear pain, fatigue, heada He reports he has exercised induced asthma which has been la receive his annual flu vaccine. PMHx child/adult illness/hospitalizations/immunizations Childhood exercised induced asthma with no recent exacerbations. No hospitalizations, trauma or other injuries Immunizations: States his immunizations are Onset: Most symptoms appeared 1-2 days ago Location: Mostly throat, Headache and Ear Duration: Every day and symptoms have persisted since onse Character: He reports 2/10 severity of ear pain which is nonsharp. Sore throat of 6-8/10 severity which is non radiating an cut. Headache is mild and just annoying. Aggravating/alleviating factors: Sore throat is aggravated b swallowing. Related symptoms: Fatigue and myalgia

with onset of other ago. Denies exposure to any sick people. Treatments: He has tried ibuprofen for pain Significance: He feels exhausted and he is missing class SurgHx type/when/why/complications Never for Surgical history. current for college. He has not received the Flu vaccine this year. FamHx Grandparents (if known)/Parents/siblings/children He has no knowledge of his grandparents medical history. Mother-age 58-Hypertension Father-age 57-Healthy SHx Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relatio Alcohol—Denies any recent alcohol intake, but occasionally night after studying. Tobacco—Denies any history of smoking, vaping, or other to Denies Recreational drug use. Relationships: Single Reproductive Hx

Female: Age of menarche/menstruation cycle duration/gravida para status/Childbirth hx/sexual hx and concerns/LMP/menopause Breast/cervical screening (if any) Male: Sexual hx and concerns/issues with fertility (if any)/Testicular or prostate screening (if applicable) Screening for STI’s (if applicable) Male patient not currently sexually active Full-time student, not planning on working during the first sem Denies any recent travel outside country in the past 2 weeks Case: Date: Allergies (Food, Drug, Environmental, etc.) List of Medications/supplements (prescription, OTC, compl alternative therapies) Ibuprofen used occasionally for pain. Review of Systems: (ROS) Use this column to document the ROS below. General : Denies any weight gain or loss HEENT : Denies vision changes. Complaints of sore throat, cough, right ear pain and headache Pulmonary : Denies shortness of breath. Reports From the ROS: list/highlight the current symptoms/compl list of pertinent “reported

or denied” symptoms below: Pertinent Positive ROS: Reports headache; Sore throat that w and swallowing, 6-8/10 pain scale; sharp ear pain that does no part of the body rate scale of pain at 2/10. He feels exhausted Case: Date: cough. CV : Denies any chest pain. GI : Denies nausea, vomiting, diarrhea or constipation. GU : No complaints of urinary problems MS : Complaint of myalgia Heme : No complaints of bleeding or bruising Lymph : Endocrine : No complaint of polyuria, polydipsia Derm : Denies any rash or lesion. Neuro : No complaints of tingling to Lower extremities Psych : Denies feeling hopeless and sad pains all over his body. Pertinent Negative ROS: Denies shortness of breath or whee denies chest pain. Physical Exam: (PE) Use this column to document the PE below. Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%)

Temperature: 100. Pulse: 88 Blood pressure: 122/82 mmHg - Sitting Respiratory rate: 16 bpm SpO2: 98% on room air Weight 185 lbs. Height 6’0” BMI 25. General : HEENT : Normocephalic, head atraumatic, Pupils reactive, Right ear shows slightly red tympanic membrane, Bilateral red, From the PE: list/highlight the presence or absence of obje generate a list of pertinent “(+) or (-)” symptoms below: Pertinent Positive PE findings: Right eat shows red tympan bilateral red erythematous/edematous pharynx. Positive anteri nodes. Scattered fine crackles of lungs on auscultation. Pertinent Negative PE Findings: Negative for wheezing, Th non palpable. Symmetrical respirations and no abnormal retra erythematous, and edematous pharynx.

Neck : Anterior cervical lymph nodes. Negative thyroid enlargement Pulm : Bilateral scattered fine crackles, Negative for wheezing, Thoracic lymph node non palpable, Symmetrical respirations, and no abnormal retractions. CV : HR 88. Normal heart sounds GI : Soft round and no tenderness. BS active X 4 GU : Normal genitalia, no tenderness or masses and no urethral discharge Neuro : Cranial nerves I-XII intact, Normal gait and posture MSK : ROM normal, equal bilaterally. Psych : No cognitive impairment Lab/Radiology or other Diagnostic data: Rapid Strep antigen detection test (RST/RADT)

• Negative COVID – 19 PCR (swab) Complete blood count (CBC) – Normal except for slightly elevated WBC (11,500) Rapid influenza diagnostic test (RIDT) - Positive Case: Date: Problem Statement: 18 month is a 22-yearold male presen symptoms for the past 1- 2

days. He reports of non-radiating e of 2/ that is sharp as well as a sore throat with intensity of 6 aggravated by cough and swallowing. He also has a complain fatigue. He has a medical history of asthma with no recent exa otherwise, PMH/Surgical HX/FH was reviewed and non-sign recreational drug use and tobacco use; he reports occasional w shows scattered fine crackles of the lungs, low grade fever, an IHUMAN TOTAL CASE SCORES: #1: 74% lymph nodes, and bilateral red erythematous/edematous phary List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding) #2: 58% Based on patient’s age/risk factors, what preventive screening would be recommended at today’s or a future visit: Grade A Screening for High BP in adults 18 years and older

HIV screening although not currently sexually active, he has been in the past. Grade B Screening for unhealthy drug use in adults 18 years and older _Include ICD 10 codes after each_* Must not Miss/Leading The myalgia, fatigue, low grade fever, nonproductive cough throat is more indicative of influenza as well as the positive test. Influenza (J11.1) is the most conclusive diagnosis. Covid – 19 (U07.1) must be ruled out since there is a pandem symptoms of cough and sore throat as well as the myalgia. Ne out COVID- 19 Group A Streptococcus pharyngitis (Strep throat) (B95.0) rule strep antigen test. Community Acquired Pneumonia (CAP) (J18.9) – negative hy productive cough makes it a less like diagnosis

1. History Questions (Interview Questions) - Onset & Duration: o When did the cough start? o Has the cough been continuous or intermittent? - Characteristics:

o Is the cough productive (producing mucus) or dry? o Describe the color and consistency of any sputum. o Any associated barking or honking sounds?

• Severity & Timing: o Is the cough worse at night or during the day? o Does the cough interfere with sleep or daily activities?
• Associated Symptoms: o Fever, chills, or sweating? o Shortness of breath or difficulty breathing? o Nasal congestion, runny nose, or post-nasal drip? o Sore throat or hoarseness? o Vomiting after coughing fits?
• Exposure History: o Recent exposure to sick contacts (e.g., daycare, family members)? o Travel history or exposure to new environments? o Exposure to environmental irritants (smoke, pollution, allergens)?
• Medical History: o Previous episodes of similar cough? o History of asthma, allergies, or other respiratory illnesses? o Recent illnesses or hospitalizations?
• Medication History:

o Current medications, including over-the-counter and herbal supplements. o Use of any inhalers or nebulizers previously.

• Social History: o Living conditions (e.g., exposure to pets, presence of smokers at home)? o Daycare or preschool attendance? 2. History
• Past Medical History: o Birth History: ▪ Term or preterm birth, any neonatal complications? o Developmental Milestones: ▪ Age-appropriate development or any delays? o Chronic Conditions: ▪ History of recurrent respiratory infections, asthma, eczema, or other atopic conditions. o Immunization Status: ▪ Up-to-date with vaccinations, including influenza and pneumococcal vaccines.
• Family History: o Family members with asthma, allergies, or other chronic respiratory conditions? o Genetic disorders that may predispose to respiratory issues?
• Social/Environmental History:

o Smoke exposure at home (tobacco, wood-burning stoves)? o Presence of pets or exposure to other allergens? o Socioeconomic factors that may affect health (access to healthcare, nutrition)?

3. Physical Exam - General Appearance: o Alert, interactive, irritable, or lethargic? o Signs of respiratory distress: nasal flaring, grunting, or use of accessory muscles. - Vital Signs: o Temperature: Assess for fever. o Heart Rate: Tachycardia may indicate distress or infection. o Respiratory Rate: Elevated in respiratory distress. o Oxygen Saturation (SpO₂): Hypoxemia if below normal range. o Blood Pressure: Less commonly assessed in toddlers but important if systemic illness is suspected. - HEENT (Head, Eyes, Ears, Nose, Throat): o Head: Check for signs of trauma or increased intracranial pressure. o Eyes: Conjunctivitis, redness, or signs of dehydration. o Ears: Signs of otitis media (ear pain, pulling at ears). o Nose: Nasal discharge, obstruction, or signs of allergic rhinitis. o Throat: Pharyngeal erythema, exudate, or tonsillar hypertrophy.

• Respiratory Exam: o Inspection: Chest symmetry, use of accessory muscles. o Palpation: Tenderness, subcutaneous emphysema. o Percussion: Dullness (possible consolidation) or hyperresonance (possible asthma). o Auscultation: ▪ Normal Breath Sounds: Vesicular. ▪ Abnormal Sounds: Wheezing, crackles, rhonchi, decreased breath sounds, stridor.
• Cardiac Exam: o Heart sounds: Regular rhythm, presence of murmurs. o Peripheral perfusion: Capillary refill, cyanosis.
• Abdomen: o Soft, non-tender, no hepatosplenomegaly.
• Skin: o Rashes, pallor, cyanosis, or signs of dehydration. 4. Assessment/Tests A. Diagnostic Testing:

1. Laboratory Tests: o Complete Blood Count (CBC): ▪ Indications: Suspect bacterial infection (elevated white blood cells), anemia, or other hematologic conditions.

▪ Details: Differential count to assess for neutrophilia or lymphocytosis. o C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): ▪ Indications: Assess for inflammation or infection. o Blood Cultures: ▪ Indications: If sepsis or severe bacterial infection is suspected.

2. Imaging Studies: o Chest X-ray (CXR): ▪ Indications: Suspect pneumonia, foreign body aspiration, or structural anomalies. ▪ Details: Look for infiltrates, consolidation, hyperinflation, or air trapping. o Neck X-ray: ▪ Indications: Suspect croup (steeple sign) or epiglottitis.
3. Respiratory Testing: o Pulse Oximetry: ▪ Indications: Assess oxygenation status. ▪ Details: Continuous monitoring if hypoxemia is present. o Spirometry or Peak Flow (if age-appropriate): ▪ Indications: Assess for obstructive airway disease like asthma.
4. Microbiological Tests: o Nasopharyngeal Swab:

▪ Indications: Test for respiratory viruses (RSV, influenza, COVID-19, adenovirus). ▪ Details: Rapid antigen tests or PCR-based assays. o Sputum Culture: ▪ Indications: If there is a productive cough with purulent sputum. ▪ Details: Identify bacterial pathogens and antibiotic sensitivities. o Viral Panel: ▪ Indications: Comprehensive screening for multiple respiratory viruses.

5. Specialized Tests: o Bronchoscopy: ▪ Indications: Suspect foreign body aspiration or severe airway obstruction. o CT Scan of the Chest: ▪ Indications: Detailed imaging if complicated pneumonia or structural anomalies are suspected. B. Assessment Based on Test Results:

• Integrate clinical findings with test results to narrow down differential diagnoses.
• Reassess if initial treatments are ineffective based on follow-up evaluations and test outcomes. 5. Diagnosis (Differential)

1. Upper Respiratory Infection (Viral): o Features: Gradual onset, runny nose, mild cough, low-grade fever. o Common Viruses: Rhinovirus, adenovirus, parainfluenza.
2. Bronchiolitis: o Features: Wheezing, difficulty breathing, often in younger children (<2 years). o Common Cause: Respiratory Syncytial Virus (RSV).
3. Asthma/Reactive Airway Disease: o Features: Recurrent wheezing, triggers include allergens or viral infections. o History: Previous episodes, family history of atopy.
4. Pneumonia: o Features: High fever, productive cough, localized crackles or decreased breath sounds. o Causes: Bacterial (e.g., Streptococcus pneumoniae), viral.
5. Foreign Body Aspiration: o Features: Sudden onset of coughing, choking, unilateral wheezing or decreased breath sounds. o History: Acute onset, possible witnessed choking event.
6. Croup (Laryngotracheobronchitis): o Features: Barking cough, stridor, hoarseness. o Common Cause: Parainfluenza virus.
7. Pertussis (Whooping Cough):

o Features: Paroxysmal coughing fits, whooping sound, possible apnea in young children. o Vaccination Status: Check immunization records.

8. Gastroesophageal Reflux Disease (GERD): o Features: Cough associated with feeding, irritability, possible vomiting.
9. Allergic Rhinitis: o Features: Itchy, watery eyes, sneezing, clear nasal discharge.
10. Congestive Heart Failure: o Features: Tachypnea, poor feeding, hepatomegaly, signs of fluid overload. 6. Plan A. Treatment
11. Supportive Care: o Hydration: ▪ Encourage oral fluids; in severe cases, consider IV fluids. o Nutrition: ▪ Maintain regular feeding; small, frequent meals if the child is irritable. o Rest: ▪ Ensure adequate rest and a comfortable environment. o Fever Management: ▪ Medications: Acetaminophen (Tylenol) or Ibuprofen (Advil, Motrin) as per weight-based dosing.

▪ Non-Pharmacological: Teething rings, cool compresses.

2. Medications: o Bronchodilators: ▪ Indications: Wheezing, diagnosed asthma or reactive airway disease. ▪ Agents: Albuterol (via nebulizer or metered-dose inhaler with spacer). o Corticosteroids: ▪ Indications: Moderate to severe asthma exacerbations, croup. ▪ Agents: Prednisone, dexamethasone. o Antibiotics: ▪ Indications: Bacterial pneumonia, pertussis, otitis media. ▪ Agents: Amoxicillin for pneumonia; macrolides for pertussis. o Antivirals: ▪ Indications: Influenza within 48 hours of symptom onset. ▪ Agents: Oseltamivir. o Antitussives and Expectorants: ▪ Caution: Generally not recommended in young children; focus on hydration and humidified air. o Nebulized Hypertonic Saline: ▪ Indications: Bronchiolitis to help clear mucus.
3. Specific Treatments Based on Diagnosis: o Foreign Body Aspiration:

▪ Intervention: Urgent bronchoscopy for removal. o Croup: ▪ Dexamethasone: Single dose for mild to severe cases. ▪ Nebulized Epinephrine: For moderate to severe stridor. o Pneumonia: ▪ Antibiotic Therapy: Based on likely pathogens and local antibiogram. o Asthma: ▪ Long-Term Management: Inhaled corticosteroids, leukotriene inhibitors. ▪ Acute Exacerbation: Short-acting beta-agonists, systemic steroids. o Pertussis: ▪ Antibiotics: Macrolides to reduce transmission and severity.

4. Adjunctive Therapies: o Humidified Air: ▪ Indications: Helps soothe irritated airways in croup and bronchiolitis. o Nasal Suctioning: ▪ Indications: Clear nasal passages in infants with nasal congestion. o Positioning: ▪ Indications: Elevate the head to ease breathing in bronchiolitis or pneumonia.

B. Follow-Up Care

1. Immediate Follow-Up: o Observation Period: Monitor response to initial treatment in the clinic or emergency setting. o Reassessment: Vital signs, respiratory status, and overall condition post-treatment initiation.
2. Short-Term Follow-Up: o Return Visit: Within 2-3 days if symptoms persist or worsen. o Emergency Signs: ▪ Increased difficulty breathing, persistent high fever, decreased oral intake, lethargy, or cyanosis—seek urgent care.
3. Long-Term Follow-Up: o Chronic Conditions: ▪ Schedule appointments with pediatric pulmonologist or allergist if asthma or allergies are diagnosed. o Vaccination: ▪ Ensure up-to-date immunizations, especially influenza and pertussis. o Developmental Monitoring: ▪ Assess for any delays or impacts from prolonged illness.
4. Parental Education: o Warning Signs: Educate caregivers on signs of respiratory distress, dehydration, and when to seek immediate medical attention.

o Medication Administration: Proper use of inhalers, spacers, nebulizers, and dosing schedules. o Environmental Modifications: Reduce exposure to smoke, allergens, and irritants. o Hygiene Practices: Handwashing to prevent spread of infections.

5. Home Care Instructions: o Symptom Management: Use of cool-mist humidifiers, maintaining a smoke-free environment. o Fluid Intake: Encourage regular fluids to prevent dehydration. o Rest: Ensure the child gets adequate rest and sleep. o Nutrition: Offer favorite foods to maintain appetite despite illness. C. Testing Follow-Up
6. Review Test Results: o Timely Interpretation: Analyze laboratory and imaging results promptly to guide treatment adjustments. o Further Testing: Order additional tests if initial results are inconclusive or if the patient is not responding to treatment as expected.
7. Specialist Referrals: o Pediatric Pulmonologist: For chronic or severe respiratory conditions. o ENT Specialist: If there are recurrent ear infections or suspected structural abnormalities. o Allergist/Immunologist: If allergies or immune deficiencies are suspected.