NRNP 6541 - Week 4 iHuman Assignment, Exams of Nursing

Download NRNP 6541 - Week 4 iHuman Assignment and more Exams Nursing in PDF only on Docsity! TEST BANK The information contained on this document has been tested and edited by professors from various universities. By purchasing this product, we guarantee you that you will get an A+. Wishing you success in your studies! With a 100 % Approved Questions and Answers Guaranteed A+ Grade NRNP 6541 - Week 4 iHuman Assignment Nick Roberts 2-year-old male 2’10” 27 lbs. (12.3 kg) Reason for encounter: Runny nose, cough, fever Observations: Patient is laying on exam table. Skin is warm and dry. Questions:  How can I help him today?  Patient’s mother (Renee) reports that 2 days ago he started with a runny nose and cough. Then yesterday the daycare sent him home for a fever. He has been fussy this morning as well and he had a fever. So now we’re on day 3 of him not being well. I was hoping to get some medication for his cough today because I’m not sure what is making him so fussy!  Does he have any other symptoms or concerns we should discuss?  Besides the cough, fever, runny nose, and fussiness…he has also not been eating as well. He has been drinking his milk normally, about 18 ounces of while milk per day. But his appetite for food has been a little decreased. He seems to be a little picky the last couple of days.  How high is his fever?  The highest it has been at home is 101F. The daycare sent him home yesterday for a fever of 100.9F.  What treatments has he had for his fever?  Tylenol every 4 hours when he has a fever. It goes away with Tylenol but returns about 4 hours later.  Does his fever keep him from sleeping?  He woke up several times last night crying with a fever.  When did his cough start?  2 days ago  Does anything make his cough better or worse?  Not really.  Is he coughing up any sputum?  No. Past Medical History: None Hospitalization/Surgeries:  Normal full-term vaginal delivery  Breastfed until 1 month of age, then was provided formula  Now transitioning off bottle and on to table foods and whole milk Medications: None Allergies: None Preventative Health: He has met all developmental milestones for his age. He has had regular well checks. He has been at the 50th percentile for both height and weight. Immunizations: Birth: Hep B 2 Months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B 4 Months: DTaP, IPV, HIB, PCV13, Rotavirus 6 Months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st Dose 7 Months: Influenza 2nd dose 12 Months: MMR, Varicella, Hep A 1st Dose 15 Months: DTaP, HIB, PCV13 18 Months: Hep A 2nd dose due today Family History:  Father (35) – has mild intermittent asthma, uses albuterol as needed  Mother (31) – no medical problems  Brother (5) – healthy  Maternal Grandmother – Died of “natural causes” at 69  Maternal Grandfather – Died at age 70 of stroke  Paternal Grandmother – Died in her 60’s unknown cause  Paternal Grandfather – Died in early 60’s unknown cause Social History  He lives in an apartment with mother, father, and 5 year old brother. Both parents smoke at home. They have one dog, a Chihuahua at home.  Parents’ Employment: Father – customer service representative; Mother – office manager Reason for Encounter: Cough, runny nose, fever HPI: Nick Roberts is a 2-year-old Caucasian male that presents to the office with his mother Renee for complaints of runny nose, cough, and fever. The patient’s mother reports that the runny nose and cough began two days ago. The cough is dry and has no sputum production. There isn’t anything that makes the cough or runny nose better or worse. The cough hasn’t had any change over time. He has not had any treatments for his cough or runny nose. His mother has not noticed her child pulling on his ears. She believes he may have pain because he has been so fussy, but her son is not able to tell her where. Nick attends daycare daily and was sent home yesterday for a fever of 100.9F. All morning the patient has been fussy with a fever of 101 F at home. His mother states that he receives Tylenol every four hours when he has a temperature, which causes the fever to subside, but it returns a few hours later. His mother reports that he woke up several times last night crying with a fever. His mother also reports that he has had decreased appetite and has not been eating well. The patient has been drinking normally, about 18 ounces of whole milk in his sippy cup, but his appetite for food has been decreased the last couple of days. She reports no nausea and no vomiting. The patient has no past medical history and is not taking any prescriptions medications. He had contact with other sick children at daycare. Patient did not receive an influenza vaccination this year. Problem Statement: Nick Roberts is a 2-year-old Caucasian male that presents to the office with his mother for complaints of runny nose, cough, and fever. The patient’s mother reports that the runny nose and cough began two days ago. The cough is dry and has no sputum production. Nick attends daycare, where other children have gotten sick with similar symptoms. + Fussiness and decreased appetite. Patient did not receive influenza vaccination this year. Temperature 102.2 F (oral). Physical examination reveals bilateral tympanic membrane with erythema and severe bulging and pharynx with erythema and exudate. Physical Examination Vitals:  Temperature: 102.2 F (oral)  Pulse: 88 regular rhythm, normal strength  Respiration: 20 – regular rhythm, unlabored effort  Blood Pressure: 95/60 (left arm) : normotensive, pulse pressure: normal  SpO2 - 94% on room air  Skin, Hair, Nails:  Inspect skin overall  Skin is warm and dry. No lesions seen. Normal skin turgor.  Test capillary refill – fingers  Capillary refill less than three seconds.  HEENT  Inspect/Palpate Scalp  No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions. Non-tender.  Inspect/Palpate Head  Normocephalic, atraumatic. No deformities. Facial feature symmetric. Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non-tender.  Inspect eyes  Eyelids: no ptosis, erythema, or swelling.  Conjunctivae: pink, no discharge  Sclerae: anicteric  Orbital area: No edema, redness, tenderness or lesions noted  Perform Fundoscopic Exam with Ophthalmoscope  Red reflex bilaterally. Optic disks sharp.  Inspect Ears  Normal appearing external structures. No deformities or edema. No discharge noted.  Look in Ears with Otoscope  Normal-appearing external auditory canals. Bilateral tympanic membrane with erythema and severe bulging. No scarring, discharge, our purulence noted.  Inspect Nose  No discharge or polyps. No edema or tenderness over the frontal or maxillary sinuses.  Look Up Nostrils  No polyps or discharge.  Inspect mouth/pharynx.  Pharynx with erythema and exudate. Tongue normal color, symmetrical. No swelling or ulcerations. Normal gag reflex. Otitis Media (OM) refers to middle ear inflammation or infection and covers a variety of middle ear issues. Otitis media usually affects children under the age of two and typically manifests with fever and otalgia in a child that is systemically unwell. It is a prevalent childhood disease and approximately 75% of children have experienced one episode of otitis media by the time they turn five. According to a global systematic analysis, there are 709 million new cases of acute otitis media each year with more than half affecting children under the age of five (Al- Hammar et al., 2018) Test/Results:  (CPT Code 87798) Bordetella Pertussis PCR – Negative  (CPT Code 87880) Group A Streptococcal Rapid Antigen Test – Negative for Group A Streptococcus Antigen  (CPT Code 87400) Rapid Influenza Diagnostic Test (RIDT) – Negative for influenza A & B  (CPT Code 87070) Throat Culture – Normal mixed flora. Negative for Group A Streptococcus Guidelines used to develop this primary diagnosis (5 points) On physical examination, when checking his ears with the otoscope, Nick was observed with bilateral tympanic membrane erythema and severe bulging. Additionally, his pharynx was noted with erythema and exudate. Patient had elevated Temperature of 102.2 F (oral) with associated non-productive cough, runny nose, fussiness, and decreased appetite. Based upon physical examination findings, as well as negative test results, the correct diagnosis for Nick is Acute Otitis Media. Differential Diagnoses (3-5 Dx with rationale and resources) (5 points)  Influenza – ICD-10 Code: J10.1 Influenza is a highly contagious acute respiratory disease that occurs in outbreaks worldwide, usually in the winter months. It is commonly difficult to distinguish from other viruses and there is no single symptoms or sign that defines testing or treatment. Common symptoms include runny or stuffy nose, cough that worsens, sore throat, headache, body aches, tiredness/fatigue, and fevers (Hsing et al., 2022). This diagnosis should be considered as a “must not miss” diagnosis, especially since it is difficult to distinguish from other respiratory conditions. Nick presented with a high fever of 102.2 F (oral), runny nose, non-productive cough, fussiness, and difficulty sleeping at night. His symptoms should be considered with this diagnosis. A Rapid Influenza Diagnostic Test (RIDT) was ordered and came back negative for influenza A & B. Influenza can be ruled out as a diagnosis.  Group A Streptococcal Pharyngitis – ICD-10 Code: J02.0 The most common bacterial cause of pharyngitis is infection by Group A Streptococcal Pharyngitis, also referred to as Strep Throat. Each year there are more than 616 million new cases globally. Symptoms commonly include red sore throat, pain when swallowing, fever, chills, swollen and tender lymph nodes, headache, muscle ache, and malaise. Additional associated symptoms may include abdominal discomfort, nausea, and vomiting (Mustafa & Ghaffari, 2020). This diagnosis should also be considered as a “must not miss” diagnosis. It is often challenging to make a correct differential diagnosis based upon a patient’s symptoms alone. Nick did present with fever and was noted with erythema of the pharynx during physical examination. He did not have any additional symptoms associated with this disease. A Group A Streptococcal Rapid Antigen Test was ordered and patient tested negative for Group A Streptococcus Antigen. Additionally, a Throat Culture was also ordered, which was negative for Group A Streptococcus. With these two negative test results, Group A Streptococcal Pharyngitis can be ruled out.  Pertussis – ICD-10 Code: A37.0 Pertussis is still a health concern, despite an increase in vaccination rates. It is caused by the bacterium Bordetella pertussis and tends to cause significant morbidity and mortality in infants and children (Yeung et al., 2017). Symptoms include runny or stuffed nose, low-grade fever, mild occasional cough, and apnea. Aerosol droplets are used to spread the extremely contagious pathogen known as Bordetella pertussis. The national immunization program (NIP) in the majority of high-income countries include a five-dose diphtheria, tetanus, and acellular pertussis (DTaP) schedule. (Macina & Evans, 2021). This diagnosis should be considered as a “must not miss” diagnosis. Nick did have a runny nose and cough, but he was running high fevers of 102.2F (oral). A Bordetella Pertussis PCR test was ordered and the results are negative. Therefore, this diagnosis can be ruled out. Medications (include OTC, dosage, and education, additional ancillary tests needed, referrals and follow up) (10 points)  Medications: Amoxicillin 250mg/5mL – Sig: give 10 mL (500mg) PO twice daily x 10 days. Dispense: 200 mL Bottle, No Refills.  Patient Education o Educate patient’s mother regarding antibiotics and the importance of completing the course, even if her son is feeling better. o Educate the parents regarding smoking cessation and how second-hand smoke can present risk factors toward their child. o Educate the parents on the importance of childhood vaccination and how it can protect their son from serious diseases. Patient is eligible to receive yearly influenza vaccination when the patient is feeling better. Encourage their consent with this vaccination.  Additional Ancillary: N/A  Referrals: N/A  Follow-ups: Patient is to return to the office in 10 days for re-assessment or sooner if symptoms don’t improve. Problem Statement (5 points) Nick Roberts is a 2-year-old Caucasian male that presents to the office with his mother for complaints of runny nose, cough, and fever. The patient’s mother reports that the runny nose and cough began two days ago. The cough is dry and has no sputum production. Nick attends daycare, where other children have gotten sick with similar symptoms. + Fussiness and decreased appetite. Patient did not receive influenza vaccination this year. Temperature 102.2 F (oral). Physical examination reveals bilateral tympanic membrane with erythema and severe bulging and pharynx with erythema and exudate. Social Determinants of Health to Consider, Health Promotion and Risk Factors (5 points)  Social Determinants of Health to Consider o Access to Housing – Patient resides in an apartment complex in town with his 5- year-old brother, parents, and dog. He has adequate housing and a good family life. o Child Care – Patient attends daycare throughout the week while his parents are at work.  Health Promotion o You can protect your child from serious diseases with vaccinations. It is important to keep your child up to date with their vaccination schedule. Continue to educate patient’s parents regarding receiving yearly influenza vaccination when patient is feeling better. 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 Formula Feeding – Patient was only breastfed for one month and then switched over to formula feeding. Breastfed infants experience substantially fewer viral upper respiratory tract infections (Al-Hammar et al., 2018). o Daycare – During the first two years of life, children that attend daycare have a higher prevalence of respiratory infections, including otitis media, than children who stay at home (Al-Hammar et al., 2018). o Exposure to Second-hand Smoke – Both of patient’s parents are smokers, exposing the child to second-hand smoke. Acute respiratory infections are commonly linked to smoke and environmental pollutants, particularly in children under the age of two (Al-Hammar et al., 2018). References