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A test bank containing a pediatric patient assessment. The patient is a 1-year-old female with dry, itchy skin patches. observations, questions, and milestones for 7-12 months. It also includes past medical history, active problems, and hospitalization/surgeries. useful for students studying pediatric nursing or medicine.
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NRNP 6541 - Week 2 iHuman Assignment Rosa Perez 1 year old female 2’7” 22 lbs. (10 kg) Reason for encounter: Well Visit age 12 months with new onset of dry, itchy skin patches. Observations: Patient is laying on exam table in diapers. Skin is warm and dry. Questions: How can I help her today? We are here for a 12 month well visit today. What has been happening since her last visit? I think I already told you. Does she have any other symptoms that you would like to discuss? Yes. I am concerned about these dry red patches on her skin. When did her rash start? 3 weeks ago What are the events surrounding the start of her rash? I don’t know. I just started noticing it about 3 weeks ago. Just a few little lesions. More recently it has gotten worse. Since she seemed fine, I waited for this visit I already had scheduled. Was that the right thing to do? On what part of her body did the rash start and where did it spread? These lesions started behind her knees, and she has had a few in the creases of her elbows. Does her rash come and go? I’m not sure. First I thought I saw something, but then it went away, but now it came back and is worse. So I guess the answer is really yes. Is her rash painful or itchy? Itchy Does she have any other symptoms associated with her rash? Not that I have noticed. Does anyone in her family have a similar rash? No What treatments has she had for the rash? I put some lotion on it, but it didn’t seem to help. Does anything make her rash better or worse? Not that I have noticed. Does the rash keep her from sleeping?
Two. Usually, one in the morning and one in the evening. How many ounces of milk does your child drink per day? She usually has 4 sippy cups of milk per day. Is your child eating solids yet? Yes. Is your child hitting her developmental milestones? Yes Has she had any recent acute or chronic infections? No How is her overall health? Pretty good. Does your child sleep through the night? Yes. Has she been having fevers? No. Has she had any contact with other sick people? No. Has she recently traveled? Where did she go? Uh…no. Does she have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? No. Does she have a problem with fatigue/tiredness? No. Is she having difficulty sleeping? No. Does she nap during the day? Yes. An afternoon nap for 3 hours at daycare and sometimes even longer at home on the weekends. On average, how many hours per night does she sleep? Typically, she sleeps 10 to 12 hours overnight. Does she awaken frequently from sleep? No. How is her appetite? Any recent change? Not really. She has always been a good eater. She seems to be enjoying her food. Has she been eating anything out of the ordinary lately? Not that I am aware of, but she is at daycare during the week. Can you tell me about her diet. What does she normally eat? She eats three meals daily. Breakfast and dinner are at home. She eats lunch at daycare. She gets a variety of meats, grains, fruits, and vegetables. She likes eggs, toast, and milk for breakfast. For dinner we cook normal Latina meals like meats, beans, and she gets milk or water. I do offer fruit for dessert and an
occasional popsicle. She has mastered the sippy cup and we are lucky she still stays in her highchair. Any diet changes since last appointment? Yes, she no longer breastfeeds. I weaned her from the breast and allowed her to eat more like a “toddler”. She enjoys feeding herself with finger foods and gets all her fluids from a sippy cup. She is not picky at all and seems a lot more content to feed herself like her big sister. She loves milk. Does your child have a diaper rash? No. Does your child say mama/dada? Yes At what age did you child start walking? She has not started walking on her own yet. Does she experience chest pain, discomfort or pressure, pain/pressure/dizziness with exertion of getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Uh…no. Does she experience shortness of breath, wheezing, difficulty catching her breath, chronic cough, or sputum production? No. Are there any guns in her home? If so. Are they stored in a safe location? No. Is she exposed to secondhand smoke? No. 10-12 Month Milestones COMMUNICATION: Meaningful uses “mama” or “dada” – Yes Imitates speech sounds – Yes Babbling has sounds and rhythms of speech – Yes Responds to “no” – Yes Responds to simple directions – Yes Pays attention to where you are looking and pointing – Yes Produces long string of gibberish – Yes Says one or two words – Yes Begins using hand movements to communicate wants and needs – Yes FEEDING: Finger feeds self – Yes
Explores and examines an object using both hands and mouth – Yes. Turns several pages of a chunky book – Yes. Experiments with the force needed to pick up different objects – Yes. Focuses on objects near and far – Yes. Investigates shapes, sizes, textures – Yes. Observes environment from a variety of positions – Yes. Enjoys a variety of movement (bouncing, rocking, etc.) – Yes. COMMUNICATION Imitates sounds – Yes. Uses increased variety of sound combinations in babbling – Yes. Participates in two-way communication – Yes. Recognizes the sound of their name – Yes. Looks at familiar objects and people when named – Yes. Follows some routine commands when placed with gestures – Yes. Shows recognition of commonly used words – Yes. Simple gestures, ex: shaking head for “no” – Yes. FEEDING In a highchair, holds and drinks from a bottle – Yes. Begins to eat thicker pureed and mashed table foods – Yes. Enjoys chew toys that can massage sore and swollen gums – Yes. Stays full longer after eating – Yes. Starts to look and reach for objects – Yes. Shows strong reaction to new smells and taste – Yes. Past Medical History No Patient Record – Obtain history Have Patient Record – Update allergies, medications, OTC drugs Active Problems: None Hospitalization/Surgeries: OBSTETRICAL: Full term, 37 weeks, NSVD, Apgars 8, Routine nurse care. HBV given at birth.
Newborn metabolic screen Normal Newborn hearing test: Passed bilaterally. Breastfed. HOSPITALIZATIONS: None SURGICAL: None. GROWTH CURVES: See patient forms section to view. Medications: None Allergies: Medication Allergies: None Food Allergies: None Stinging Insects: None Environmental Allergies: None Preventative Health: Immunizations: Up to Date Carseat: Rear facing carseat, backseat middle Safety: Home childproofed, no guns, no smokers Pets; Sister has an iguana Childcare: Full time daycare Lead Screening: The family home was built in 1960 and has original plumbing. Dietary Supplement: Iron and Vitamin D daily. Immunizations:
Denies any shortness of breath, wheezing, difficulty catching her breath, chronic cough or sputum production. Denies any problems with nausea, vomiting, constipation, diarrhea, coffee grounds in her vomit, dark tarry stool, bright red blood in her bowel movements, early satiety, or bloating. Denies any pain, burning, blood, difficulty starting or stopping, dribbling incontinence, urgency during day or night, or changes in frequency when urinating. Denies any muscle or joint pain problems, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain. Denies any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding. Denies any problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite. Denies any problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor. Denies any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes. Reason for Encounter: Well visit age 12 months with new onset of dry itchy patches of skin HPI: Rosa Perez is a 12 month old Hispanic female who presents with her mother, Clara, to the office for her 12 month well visit with new onset of dry itchy patches of skin. Rosa’s mother reports that her daughter’s overall health is “pretty good”. Her mother denies any recent acute or chronic infections. Rosa has no known allergies. She is not taking any prescription medications and taking the recommended vitamins (iron and vitamin d) daily. All immunizations are up to date. Since her last visit, Rosa no longer breastfeeds. She was weaned off the breast and is now eating more like a toddler. She enjoys feeding herself with finger foods and drinks from a sippy cup. Her mother reports that she usually drinks 4 sippy cups of milk per day. Rosa is not a picker eater and seems happier to feed herself, like her older sister. She is a good eater and her diet consists of three meals per day – breakfast, lunch, and dinner. She eats lunch at daycare, which she attends full time throughout the week. Rosa gets a variety of meats, grains, fruits, and vegetables daily. For breakfast, she typically eats eggs, toast. Her family cooks Latina meals for dinner consisting of meats and beans. Fruit and occasional popsicle are offered for dessert. Rosa has mastered using her sippy cup and is able to stay still in her highchair for meals. She has multiple wet diapers daily, her mother stopped keeping track unless she is sick, and usually has two stool diapers – one in the morning and one in the evening. She typically sleeps about ten to
twelve hours per night. Rosa naps in the afternoon for 3 hours at daycare, and her mother reports sometimes even longer when she is at home on the weekends. Rosa’s mother reports that she has met all appropriate developmental milestones, except she is unable to stand alone and take several independent steps. Patient’s mother reports that she is concerned about “dry red patches” on her daughter’s skin. Her mother states that she developed a rash about three weeks ago. It initially started off with a few little lesions and they got worse. The lesions started behind her knees and reports there are a few in the creases of her elbows. Rosa has not had rashes like this before. Her mother states that the rash is itchy, but not painful. There isn’t anything that makes her rash better or worse. She has not noticed any other associated symptoms with her rash and does not recall any pattern to when the rash occurs. Her mother put some lotion on the affected area, but it did not seem to help. She states that the rash is not very severe. No one in the family has a similar rash. There has not been any change in her appetite. Rosa has not been eating anything out of the ordinary, but she is in daycare full time during the week. Mother reports that she is not using any new lotions, soaps, or deodorants. When the rash initially started, she changed the laundry detergent to perfume free. No one in the family has a similar rash. Problem Statement: Rosa is a 12 month old Hispanic female who presents with her mother for her 12 month well visit. She reports that her daughter’s overall health is pretty good and is meeting all of her developmental milestones. New onset of scattered dry scaly skin patches on elbow creases and behind knees noted on physical examination. + Itchiness. No other associated symptoms. Patient attends full time daycare. No fever, change in appetite, or trouble sleeping. Physical Examination Vitals: Temperature: 98.6 F (oral) Pulse: 100 regular rhythm, normal strength Respiration: 20 – regular rhythm, unlabored effort Blood Pressure: 90/60 (left arm) : normotensive, pulse pressure: normal SpO2 - 98% on room air Skin, Hair, Nails: Inspect skin overall
No visible scars, deformities, or other lesions. Trache is midline and freely mobile. Palpate Neck Supple, nontender. No meningismus or nuchal rigidity. Breast Exam Normal breast exam. Breasts and nipples non-tender. No masses, lumps, deformities, ulcerations, or discharge. Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains Chest Visual inspection of anterior and posterior chest The chest is symmetrical, and the anterior-posterior diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. Tanner Stage 1. No distension, scars, masses, or rashes Auscultate lungs The left and right lung fields normal. Heart Auscultate heart Normal heart sounds. Abdomen Visual Inspection Abdomen is flat and symmetric with no scars, deformities, striae, or lesions. Auscultate Abdomen Noromactive bowel sounds in all four quadrants. Palpate abdomen No pain, tenderness, masses, or pulsations. There is no guarding or rebound tenderness. No hepatosplenomegaly. Liver span normal. The spleen is not palpable. Percuss Abdomen No tympany or shifting dullness. Abdominal Girth Appropriate girth for age and gender. Extremities Visual Inspection Extremities There is no swelling or deformity. There is no cyanosis, clubbing, or edema. Patches of dry red skin behind knees bilaterally. Patches of dry red skin in elbow creases bilaterally. Palpate Extremities There is no tenderness, muscular resistance, rigidity, or deformity. Clavicles nontender.
Musculoskeletal Inspect for muscle bulk and tone Normal bulk and tone. No rigidity. Inspect/Palpate Back and Spine No asymmetry or deformity of the back. No tenderness of spasm of the paraspinal muscles. No localized tenderness of the spinous processes or pelvis structures. Test range of motion Normal, equal bilaterally. GU/Rectal Normal external genitalia. No masses or tenderness. Normal pelvic exam. No visible rectal fissures, induration, or lesions. Normal sphincter tone. No masses or tenderness. Guaiac negative. Neurological Sensory Tests (light touch, pain, position, temperature, vibration) Normal/symmetric light-touch sensation. Assess Cranial Nerves CN II-XII intact Look for involuntary movements. No fibrillations, fasciculations, asterixis, tics, myoclonus, dystonias, chorea, athetosis, hemiballismus, nor seizures. Test strength Strength is 5/5 bilaterally Reflexes – Deep Tendon
Management Plan Template (40 points) Primary Diagnosis (10 points – all areas must be addressed) Well-Child Status – ICD-10 Code: Z00. In the United States, a pediatrician spends approximately 40% of their time assessing healthy children and practicing preventative care. The typical well-child visits last anywhere from fifteen to thirty minutes, during which they will address any questions or concerns raised by the parents, monitor the child’s growth and development, perform a physical examination, screen for diseases that can be prevented, check for psychosocial factors that affect health, and provide guidance and education (Friedman et al., 2021). Rosa Perez is meeting all her developmental milestones and appears to be a happy and healthy child. She is tracking along the 50th^ percentile for both height and weight. She is due for
several immunizations and will be provided with her MMR, Varicella, and Hepatitis A shots in office today. Eczema – ICD-10 Code: L Eczema, also referred to as atopic dermatitis (AD), is a chronic inflamed skin disease that affects approximately 11% of children (Young et al., 2021). Persistent itching is a common symptom in children with eczema, which can interfere with the child’s sleep and adversely impact quality of life. Patients with acute flares have scattered excoriations and erythematous, scaly lesions. In more severe cases, papules and or spongiotic vesicles are visible. Lichenification and dyspigmentation are telltale signs of prolonged illness. Eczema can manifest anywhere on the body and in any age group, but it carries a distinctive age-distribution pattern that aids in identification. Antecubital and popliteal regions, wrists, ankles, and the face are frequently involved in those aged 1-3 (Sayaseng & Vernon, 2018). Guidelines used to develop this primary diagnosis (5 points) On physical examination, Rosa was observed with scattered dry scaly skin patches on elbow creases and behind her knees with evidence of excoriation. Her mother did report itching, yet no pain. She did have scattered excoriation with erythematous scaly lesions. The locations on the rash coincide with Rosa’s age group. Based upon physical examination findings and evidenced-based literature, the correct diagnosis for Rosa’s skin condition is Eczema. Differential Diagnoses (3-5 Ddx with rationale and resources) (5 points) Irritant Contact Dermatitis – ICD 10 Code: L Irritant contact dermatitis is a biphasic type of skin hypersensitivity response that occurs immediately when it contact with the substance. It presents clinically with pruritic, eczematous papules and plaques with surrounding erythema swelling, vesicles or bullae, and serous crust (Neale et al., 2021). It is important to consider this as a must-not-miss diagnosis. Rosa did not have any oozing, crusting, thickening, localized swelling, or pain. During the history taking, her mother ruled out any new soaps, lotions, or deodorants products. Rosa’s symptoms are consistent with the diagnosis of eczema. Seborrheic Dermatitis – ICD 10 Code: L Seborrheic dermatitis (SD) is one of the most prevalent inflammatory skin conditions which affects 2-8% of the population. It is a chronic inflammatory skin disorder that causes erythematous papulosquamous lesions, especially on the scalp, face, and intertriginous areas of the body (Uzuncakmak et al., 2021). Seborrheic dermatitis can be ruled out based upon its physical present and classification. Rosa did not have red or purple papules or plaques with demarcation and scales. She presented with an itchy rash that consisted of dry scaly skin patches. Psorarsis – ICD 10 Code: L
o Access to Housing – Patient resides in a home with her older sister, both married, and her maternal grandmother. She has adequate housing and a good family life. o Child Care – Patient attends day care full-time during the week, while her parents both work. Health Promotion o You can protect your child from serious diseases with vaccinations. It is important to keep up to date with their vaccination schedule. o As your child is growing and developing, and they are moving towards eating solids food, ensure that their food is cut up into small bite-sized piece to prevent choking. Instruct the child to chew their food and eat slowly. Risk Factors o Childproof the home to prevent your child from exploring new things, ex: safety lock cabinets that contain harmful cleaners which the child could potentially put in their mouth, place gate at the top and bottom of staircase as your child is beginning to walk to prevent accidental falls o Car safety – ensure your child utilizes a car safety seat every time they are in a vehicle and they should ride rear facing in the middle back seat. Invest in car monitors to always monitor your baby without having to turn around or take your eyes off the road. References Dhar, S., & Srinivas, S. M. (2022). Psoriasis in pediatric age group. Indian Journal of Dermatology, 67 (4), 374-380. https://doi.org/10.4103/ijd_570_22. Friedman, S., Calderon, B., Gonzalez, A., Suruki, C., Blanchard, A., Cahill, E., Kester, K., Muna, M., Elbel, E., Purushothaman, P., Krause, M. C., & Meyer, D. (2021). Pediatric practice redesign with group well child care visits: A multi-site study. Maternal and Child Health Journal, 25 (8), 1265-1273. https://doi.org/10.1007/s10995-021-03146-y. Neale, H., Garza-Mayers, A. C., Tam, I., & Yu, J. (2021). Pediatric allergic contact dermatitis: Part I: Clinical features and common contact allergens in children. Journal of the American Academy of Dermatology, 84 (2), 235-244. https://doi.org/10.1016/j.aad. 2020.11.002. Sayaseng, K. Y., & Vernon, P. (2018). Pathophysiology and management of mild to moderate pediatric atopic dermatitis. Journal of Pediatric Health Care, 32 (2), S2-S12. https://doi. Org/10.1016/j/pedhc.2017.10.002.
Uzuncakmak, T. K., Bayazit, S., Askin, O., & Kutlubay, Z. (2021). Demographic features and seasonal variation in adult and pediatric seborrheic dermatitis: A cross-sectional, single- center, hospital-based study. Southern Clinics of Istanbul Eurasia, 32 (2), 121-124. https://doi.org/10.14744/scie.2021.57441. Young, T. K., Glick, A. F. , Yin, H. S., Kolla, A. M., Velazquez, J. J., Nicholson, J., & Oza, V. S. (2021). Management of pediatric atopic dermatitis by primary care providers: A systematic review. Academic Pediatrics, 21 (8), 1318-1327. https://doi.org/10.1016 c /j.acap.2021.07.008.
