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218 General Adult Health OBJECTIVE General: Timothy is a slightly overweight male, sitting comfortably, in no apparent distress. Vital signs: Blood pressure: 135/80; pulse: 64 and regular; respirations: 14; temperature: 98. 6°F; height: 5 ft 10 inches; weight: 180 lbs; BMI: 25. Skin: Pale pink without rashes, lesions, or ulcers. Respiratory: Clear without wheezes or crackles. Cardiac: S1/S2 intact without murmurs, rubs, or gallops. Peripheral vascular: Skin pink, warm, and dry without edema, lesions, or ulcers. Brachial, radial, and ulnar pulses 2+ equal and strong bilaterally. Nailbeds pink with capillary refill <2 seconds bilaterally. Musculoskeletal: Neck with full range of motion (FROM) without pain. Vertebral column in “S” shape without deformity or tenderness to palpation or percussion. No pain, tingling, or numbness with compression of the head onto the cervical neck. Shoulders and elbows aligned with FROM bilaterally, without erythema, swelling, bruising, deformity, crepitus, or pain. Muscle strength 5/5. Forearms, wrist, and hands symmetrical without erythema, swelling, bruising, or deformity bilat-erally. Palms without thenar wasting with FROM intact bilaterally. Hand grip strength 5/5 bilat-erally. Right thumb abduction strength 4/5; left 5/5. Neurological: Wrist and hands: Right wrist with pain first and second digit with direct compres-sion of right median nerve; positive Phalen's test with pain and numbness. Negative Tinel's test. Sensation to light touch and 2‐point discrimination intact in forearm and fingers equal bilaterally. Deep tendon reflexes: triceps, biceps, brachioradialis, patella, Achilles 2+ bilaterally. CRITICAL THINKING What are the three most likely differential diagnoses and why?___Amyotrophic lateral sclerosis___Multiple sclerosis___Carpal tunnel syndrome___CVA___Pronator syndrome___Osteoarthritis Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___CBC___Metabolic panel___FBG___TSH___X‐ray of wrists___Nerve conduction velocity studies (NCV)___Electromyography (EMG)___MRI of neck___X‐ray of elbows___X‐ray of neck | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Hand Numbness 219 What is the plan of treatment? What is the plan for referrals and follow‐up?What specific activities do you want to ask about?What other important history questions must you ask so as not to miss an important differential diagnosis? Why do you inspect for thenar atrophy?Would your diagnosis change if Timothy complained of acute onset of paresthesias of the upper arm? Why would you be concerned if Timothy's pain were past his elbows?What significance does thumb strength have?When would you consider referring Timothy?What would you do if this patient were female and pregnant?Are there any standardized guidelines available to be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
221 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Amelia, a 25‐year‐old Caucasian female, presents to the primary care clinic with the chief com-plaint of abdominal bloating and diarrhea, worsening over the past 2-3 months. Amelia reports that she thinks she has lost weight during that time. Occasionally she comes to the clinic for acute illnesses. Her last visit was almost a year ago with flu‐like symptoms. She goes to her gynecologist annually and considers this her routine health maintenance; her last visit was 6 months ago with no significant findings. She has a self‐described long history of nonspecific gastrointestinal malaise. She feels nauseous and bloated and has inconsistent voiding patterns with a tendency toward loose stools. Over the past 2 months, however, more than 60% of her stools have been loose, double the usual. She has not noticed any change in her voiding pattern. Generalized abdominal bloating has been increasing in frequency and intensity, now occurring 4-5 times per week, generally 1 hour after eating. There is associated generalized cramping and pain that she rates as a 6/10, though she is in no pain right now. She has vomited 3 times in as many weeks without resolution of symptoms. The patient denies making herself vomit. She reports that she had to leave work numerous times because of the pain and discomfort. Lying down and applying heat make her symptoms more tolerable, but this is an unsustainable management technique; she is worried and frustrated. She has not done any recent traveling. Past medical and surgical history: Allergic rhinitis. Family history: Mother and father are alive and well, both with hypertension. Brother, 20, is alive and well with Type 1 diabetes, which he manages well. Social history: Amelia is a college graduate currently working 50 hours per week for a community development nonprofit organization. She loves her job and sleeps well—though admittedly not enough—usually 6 or 7 hours per night. She goes to the gym for an hour 3-4 times per week, has an active social life, is applying to graduate school, and is generally pleased with her life. If she could change anything, “I'd add a couple hours to the day so I could slow down a little and still get things done. I'm pretty type A, which is why this stomach thing is bothering me so much. ” She drinks 2-3 cups of coffee a day; skips breakfast; eats a bagel, yogurt, and fruit for lunch; and usually goes out or eats “healthy” takeout for dinner. She drinks socially ∼1 time per week, but denies tobacco or other drug use. Case 8. 14 Chronic Diarrhea By Clara M. Gona, Ph D, FNP‐BC, RN, and Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
222 General Adult Health Medications: Lo Ovral, daily (birth control); multivitamin daily; OTC Claritin, 1 tab PRN for allergy symptoms; OTC Mucinex, PRN for cold symptoms. Allergies: Seasonal. No known drug or food allergies. Screening and immunizations: Routine blood work last year WNL, but showed borderline iron deficient anemia. Negative Pap smear last year. She is up to date on immunizations including the HPV series. OBJECTIVE General: Well‐developed and well‐nourished but thin, 25‐year‐old female who looks her stated age. She is in no acute distress. Skin: Rash on the elbows and extensor surface of the arms. HEENT: Unremarkable. Neck: No lymphadenopathy. Respiratory: Chest, clear to auscultation. Cardiac: Regular sinus rhythm. No ectopy. Abdominal: Symmetrical, nondistended, positive BS; nontender; no organomegaly. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis? ___CBC___Comprehensive metabolic panel___TSH___Tissue transglutaminase antibodies, Ig A___Duodenal biopsy___Bone mineral density___Endoscopy___Skin biopsy___EMA___anti‐t TG What is the most likely differential diagnosis and why? ___Irritable bowel syndrome (IBS)___Celiac disease___Inflammatory bowel disease (IBD) What are other possible differential diagnoses?What is the plan of treatment?What is the plan for referrals and follow‐up?Are there standardized guidelines or resources that would help in this case?What demographic characteristics might affect this case?If this patient had no insurance or lived in a rural area without access to health care (difficult to get to a clinic), how would that change management, or would it change management? NOTE: The author would like to acknowledge the contribution to this case of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
223 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Roger, a 43‐year‐old male, presents to the primary care clinic with the chief complaint of intrac-table pain. Six months ago, Roger was riding a motorcycle when he was hit by a car and thrown. His right leg was severed below the knee, and he had extreme facial injuries. At the hospital, leg reattachment surgery was unsuccessful; so an above‐the‐knee amputation was done. He was trans-ferred to a level I trauma center, where he was intubated and trached during his 3‐week hospital-ization. He is now walking with crutches at home; he does not yet have prosthetics. His nose was fractured and repaired. He complains of leg pain that is extremely severe and uncontrollable. He reports being “at his wit's end” because nothing is treating his pain. While in the hospital, he was prescribed Percocet for pain; but at the moment he is using over‐the‐counter analgesics with no effect. Past medical and surgical history: Significant for esophageal fundoplication for severe GERD five years ago. Family history: Both parents are alive and well, ages 70 (mother) and 75 (father). His mother has hypertension, and his father has dyslipidemia. He is an only child. Social history: He reports drinking 2-3 beers weekly and smoking 1 pack of cigarettes daily. He does not use any street drugs. He works as a parcel‐delivery truck driver, but he is now on disability from work and collecting unemployment. He lives at home with his wife and 2 small children. Medications: Ibuprofen, 600 mg every 4 hours for pain; Tylenol, 650 mg every 6 hours for pain. Allergies: He has no known drug, food, or environmental allergies; and his immunizations are up to date. Case 8. 15 Intractable Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
224 General Adult Health OBJECTIVE General: Trying to smile, but obviously in pain. Alert, with a child‐like stoic look on his face. Vital signs: T: 97. 8°F; P: 76; RR: 18; B/P: 120/84. His weight was not checked as he could not stand and be stable on the scale. Skin: Good color, no lesions. HEENT: Obvious facial deformity with missing teeth. Fullness under right eye where plate was placed surgically. Severed palate is healing. Neck: No lymphadenopathy. Thyroid nonpalpable. Tracheotomy wound healing. Cardiovascular: Regular rate and rhythm. S1 and S2 are normal. Respiratory: Chest is clear to auscultation. Abdomen: Soft, nontender, and bowel sounds are present. Musculoskeletal: Full range of motion in upper extremities. Stump is wrapped with an Ace bandage. Upon inspection, the incision is clean and well healed. There is no edema. Genital: He has normal genitalia. There is no evidence of swelling. His testicular exam is normal, and there is appropriate hair growth. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis? If you choose imaging studies, state what part of the body you will image. ___X‐ray___MRI___CT scan___CBC___CMP What is the most likely differential diagnosis and why? ___Phantom limb pain___Neuropathic pain___Chronic pain related to trauma What is the plan of treatment?What is the plan for referrals and follow‐up?Are there standardized guidelines or resources that would help in this case? NOTE: The author would like to acknowledge the contribution of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
225 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Rosa, a 29‐year‐old Latina woman, presents for evaluation of wrist pain and swelling. She devel-oped symptoms about 3 months ago and has noted progressive worsening since that time. In addition, she has tenderness across the balls of her feet with any weight bearing. The pain is worse when she is inactive and improves with activity. The symptoms have significantly impacted her ability to perform her job as a receptionist in a busy office. She denies any recent trauma to her hands or feet or other joint pain. She notes stiffness in the feet and ankles as well as 4 hours of overall morning stiffness that improves only marginally for the rest of the day. She has noted increased fatigue and weakness in the last few months. She often naps when she gets home from work and has curtailed her social activities significantly. Rosa denies fever, chills or other systemic symptoms. Rosa denies dry eyes or dry mouth, changes in her vision, neck or shoulder stiffness, chest pain or difficulty breathing. She denies ever having previous episodes of these symptoms. Rosa denies any rashes, lesions or ulcers, any changes in her hair, skin or nails, any polyuria, polydipsia, or polyphagia. She does not recall being bitten by any insects recently and spends most of her time indoors. Rosa denies any weight loss, history of pregnancy or any memory changes. She is not aware of having any recent infection, nor has she experienced any problems with her bowel or bladder function. She denies numbness or tingling in any part of her body. Past medical history: None. Family history: No family history of any inflammatory or autoimmune disease, except for a cousin with systemic lupus erythematosus. Social history: Rosa is single, but several family members live nearby. She barely supports herself without assistance, but her parents occasionally give her money for extras. She denies a history of smoking or drug use. She drinks with friends on the weekends, consuming 1-2 mixed drinks or beers on Friday and Saturday evenings. She states that she is generally happy but would like to settle down with someone in a monogamous relationship. She verbalizes her fear of having a serious disease during the visit today. Medications: Rosa takes only birth control pills and a multivitamin daily. Case 8. 16 Wrist Pain and Swelling By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
226 General Adult Health OBJECTIVE General: Rosa appears to be in no apparent distress. Vital signs: Rosa weighs 110 lbs, and her height is 63 inches. She has an oral temperature of 100 degrees Fahrenheit. BP is 120/70. HR is 64 and regular. Respiratory rate is 12 and regular. HEENT: Her head is normocephalic and nontender. There are no scalp lesions or apparent alo-pecia. PERRLA, with EOMs intact. Sclerae are clear without visible scleritis. There is no malar rash or any lesions or ulcers on her face or buccal mucosa. Neck: There is no cervical or other lymphadenopathy. Her thyroid is nonpalpable. CNs II-XII are grossly intact. Cardiac: The cardiac exam reveals RRR S1/S2 with no murmurs, clicks, gallops, or rubs. Respiratory: Lungs are clear bilaterally. Skin: The skin is clear. Abdomen: Soft without organomegaly, tenderness, or bruits. Neuromuscular: There is moderate synovitis (swelling) of the MCP and PIP joints bilaterally and of the MTP joints bilaterally. The patient has limited ROM of the UE and LE digits due to pain. There are no nodules noted on any extremity. The Phalen's, Finkelstein's, and Tinel's tests are negative. There is no warmth or redness of any joint. DTRs are +2 throughout. CRITICAL THINKING What is the most likely differential diagnosis and why?___Osteoarthritis___Rheumatoid arthritis___Systemic lupus erythematosus___Carpal tunnel syndrome___Sjögren's syndrome Which diagnostic studies should be considered to assist with or confirm the diagnosis? ___Rheumatoid factor___ESR___CRP___CCP___ANA, C3, and C4___Anti‐DS DNA___CMP___CBC___HLA‐B27___SS‐B___SS‐A___Imaging studies What is the plan of treatment?What is the plan for referrals and follow‐up?Would the primary diagnosis be different if the patient were 55 years old?Would there be treatment considerations if the patient had a history of tuberculosis? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Mental Health Case 9. 1 Sad Mood 229 By Sheila Swales, MS, RN, PMHNP‐BC Case 9. 2 More Than Depression 231 By Sara Ann Jakub, MA, SYC, LPC, and Anna Goddard, Ph D, APRN, CPNP‐PC Case 9. 3 Postpartum Depression 235 By Nancy M. Terr es, Ph D, RN Case 9. 4 Anxiety 239 By Sheila Swales, MS, RN, PMHNP‐BC Case 9. 5 Trauma 241 By Erin Patterson Janicek, LCSW, and Anna Goddard, Ph D, APRN, CPNP‐PCSection 9 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
229 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Julia is an 18‐year old college student of Hispanic descent who presents with “sad mood”: episodes of unexplained tearfulness, low energy, difficulty concentrating, increased appetite, and hyper-somnia (sleeping 10-12 hours per night). She reports experiencing these symptoms throughout the day and that they have persisted for the past 5-6 weeks. Julia reports that she has fallen behind in her coursework and is at risk of failing two classes. She has been less engaged socially and reports missing a recent gathering to celebrate her best friend's birthday because she couldn't motivate herself to shower and get dressed for the occasion. She admits that she no longer feels comfortable in most of her clothes due to a recent weight gain of 8 pounds. She denies any pre-cipitating stressors but discloses that adjusting to college life and living away from her family have been more difficult than she anticipated. She misses the support and structure of family life. Julia denies experiencing suicidal ideation. Her PHQ‐9 score is 19 and she indicates that symptoms have made it “very difficult” for her to engage academically and socially. Julia states that she may have been a little depressed during her junior year of high school when a close friend abruptly distanced himself and stopped returning her calls. She has never sought treatment for depressive symptoms or any other mental health issues. Past medical history: Julia has no history of seizures or traumatic brain injuries. Family history: Julia's mother is being treated for hypertension and depression. Social history: Julia was raised in an intact family. She has close relationships with her parents and two younger siblings. She has friends, including her best friend, Amelia. She reports no current or past history of romantic relationships. Julia enjoys watching old movies and spending time outdoors in nature. She exercises several times per week. Julia describes herself as “not religious. ” She denies using alcohol, nicotine, or other substances. Medications: None. Allergies: No known allergies. Case 9. 1 Sad Mood By Sheila Swales, MS, RN, PMHNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
230 Mental Health OBJECTIVE General: Cooperative, appears tense with mildly pressured speech and psychomotor agitation. Vital signs: BP: 118/76; P: 80; R: 20; T: 98. 6°F; height: 5 feet 4 inches; weight: 142 lbs; BMI: 24. 4. HEENT/Neck: There is no JVD. Cardiovascular: There is a 2+ carotid, no bruit. Regular rate and rhythm, S1 and S2. Respiratory: Lungs are clear to auscultation and percussion. Musculoskeletal: Full range of motion of the neck and trunk. Abdomen is soft, nontender, and nondistended. Extremities show no edema, clubbing, or cyanosis. CRITICAL THINKING What are the top three differential diagnoses in this case and why? Which diagnostic tests are required in this case and why?What are the concerns at this point?What are 3-5 case‐specific questions to ask?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat her?What if the patient lived in a rural (or urban) setting?Are there any standardized guidelines that should use to treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
231 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Marc is a 19‐year‐old Hispanic male, and a senior in high school. Marc presents to the school‐based health center for a routine physical exam. The Patient Health Questionnaire (PHQ‐2) administered to Marc at the start of the physical reveals a reported feeling of hopeless nearly all the time. Marc denies loss of interest in activities but reports calling out sick from his part‐time after‐school job several times a month. The school reports a high number of school absences and grades shifting from Bs to Ds during this marking period. Past medical history: Early childhood onset asthma, history of obesity in childhood, history of self‐injurious behavior (SIB) in the form of superficial scratching skin with use of fingernails. Family history: Maternal history is positive for heart disease, high blood pressure, episodic depres-sion, and alcohol and tobacco dependence. First‐degree relative (maternal side) positive for migraine headaches. Paternal history is unknown. Social history: Marc denies current use of drugs or alcohol. He is the oldest of 4 children, father unknown, with early childhood exposure to domestic violence (DV) between mother and boy-friend, episodes of housing insecurity (multiple moves between friends' homes and stays at motels), mother works 3 jobs to provide for family, resulting in the patient providing supervision to his younger siblings. Sleep history: Difficulty initiating sleep with frequent waking throughout night, denies night-mares; average 5-6 hours per night per personal fitness tracker (Fit‐Bit) recording. Medications: Albuterol MDI. 083% inhaler PRN; Xopenex (nebulizer) PRN wheeze, Cetirizine 10 mg QD. Allergies: Environmental allergies, allergy‐induced eczema, penicillin. Review of Systems:HEENT: Ongoing congestion, no changes in hearing, no vision changes, wears glasses. Skin: No rashes. Case 9. 2 More Than Depression By Sara Ann Jakub, MA, SYC, LPC, and Anna Goddard, Ph D, APRN, CPNP‐PC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
232 Mental Health Cardiovascular: No shortness of breath, no chest pain, no history of cardiac anomalies, no murmurs. Respiratory: No shortness of breath, last used inhaler over 6 months ago, last nebulizer use unknown. Gastrointestinal: No nausea, vomiting, or diarrhea, no constipation, loss of appetite. Genitourinary: No increased frequency of pain or increased urination. Muscoskeletal: No swelling or joint tenderness. Heme: Denies easy bruising. OBJECTIVE General: The patient appears tired, is slow in responsiveness (verbally and behaviorally) to most requests, and fidgets with his clothing. He presents disheveled with dirty jeans and stains on his hooded sweatshirt; his hair is unbrushed. While placing a blood pressure cuff on Marc's arm, several thin linear scars approximately 2 inches long and 2 centimeters thick are visible. Some scars appear white; silvery in tone; one mark is pink in tone with minimal scabbing. Vital signs: Temperature: 98. 3°F; heart rate: 102; blood pressure: 128/84; RR 22. Eyes: PERRLA, EOM intact. ENT: Normal appearance of posterior oropharynx, clear rhinorrhea bilateral. Lymph: No lymphadenopathy. Cardiovascular: Tachycardia, no JVD, no carotid bruits, no murmurs, regular rhythm. Lungs: Clear to auscultation bilaterally, no accessory muscle use, no crackles or wheezes. Skin: Several thin linear scars approximately 2 inches long and 2 centimeters thick were visible. Some scars appeared white, silvery in tone; one mark was pink in tone with minimal scabbing. Abdomen: Normal bowel sounds, abdomen soft and nondistended. Genitourinary: Not examined. Musculoskeletal: No edema, cyanosis, 5/5 strength with normal range of motion, no swollen joints. Neurological: Alert and oriented X 3, CN II-XII grossly intact. CRITICAL THINKING What are the top three differential diagnoses in this case and why? __Major depressive disorder__Other specified depressive disorder__Other specified trauma disorder__Personal history of self‐harm__Hypothyroidism__Adjustment sleep disorder (acute insomnia) | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
More Than Depression 233 What diagnostic tests are required in this case and why? __Patient Health Questionnaire‐9 (PHQ‐9)__Beck Depression Inventory__Non‐Suicidal Self‐Injury Assessment Tool (NSSI‐AT)__Columbia Suicide Severity Rating Scale (C‐SSRS)__CBC with differential__Thyroid panel What are the concerns at this point?What is the plan of treatment?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history affect how you might treat him?What if the patient were elderly or under age 13? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
235 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Jake, 4 weeks old, presents to a pediatric practice in January for a weight check. He is accompa-nied by his mother, Laura. Laura says she experienced no perinatal complications, and was dis-charged 2 days postpartum, while Jake remained in the hospital for another 5 days for feeding and weight gain. Laura has been bringing Jake into the primary care office twice a week for weight checks, but this is the first time he is being seen by the nurse practitioner in the practice. Birth history: Jake was the full‐term product of a spontaneous vaginal delivery after a 10‐hour labor to a Gr 3, P1, SAB 2, 40 y. o. mother. Laura underwent several years of fertility interven-tions, which included two first‐trimester spontaneous pregnancy losses. During this recent pregnancy Laura received regular prenatal care, was healthy, and took no medications except for prenatal vitamins. She neither smoked any substances nor drank any alcoholic beverages during her pregnancy. Jake's Apgar scores were 9 at 1 minute, 9 at 5 minutes, and 10 at 10 minutes. His birth weight was 4 lbs., 10 oz. (2. 098 kg). He had an uneventful extended hospital course focused on feeding and gaining weight with breastfeeding, plus bottle feedings/day of fortified pumped breast milk or formula fortified for 24 calories/oz. every other feeding for catch‐up growth. After an initial postnatal weight loss, Jake started gaining about 30-40 gms/day while still hospitalized. His discharge weight was 4 lbs. 5 oz. (1. 9561 kg). Jake's hospital discharge plan was: Keep Jake warm, check his temperature several times a day. Breastfeed every 2 hours ar ound the clock. Reinforce pumped milk bottle feeding with a teaspoon of human milk fortifier for each 3 oz. of br east milk for 24 calories/oz. three times a day. Twice‐weekly weight checks. Social history: Before Jake was born Laura was an executive for a biomedical company, and her husband Craig is an executive for a global investment company. They live in a single‐family home in an upscale suburb of a large northeastern city. When Laura became pregnant she and Case 9. 3 Postpartum Depression By Nancy M. Terres, Ph D, RN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
236 Mental Health Craig decided that the time commitment involved with both of their careers would not be con-ducive to attentive parenting, so they made the mutual decision that Laura would stay home with Jake. Craig works long hours. He also travels regularly for work. He currently carries the health care benefits in his job, so Laura feels she cannot complain about his being away so often. Craig is a member of the local country club, and is part of a group that trains for marathons, while Laura tends to be more reserved, preferring her small circle of friends mostly from her work. None of Laura's friends are at home with babies, and Laura does not see them regularly since leaving work. Laura's parents, besides living a distance away, are elderly and in poor health, and not a direct source of support. She has a brother who lives close to her parents, but no other siblings. The paternal grandparents live in the southwest United States and are retired. When asked who she considered her main support to be, Laura said it was Craig. However, Craig is not available much of the time to help Laura with Jake. Jake's frequent feeds have created tension between the parents because Craig cannot get a full night's sleep to go into work the next day with Jake in a bassinet in the room. Laura eventually moved into Jake's room to remain close to him and to make her available for his frequent feeds without disturbing Craig. Laura has a previous history of depression since her teens that worsened during her struggles with infertility and pregnancy losses. She had an eating disorder in high school and in the early years of college, but denies any issues with eating since then. She has periodically taken Citalopram, but not in several years, and was resistant to medication while going through infertility treatments and while breastfeeding. She believes that all medications prescribed or over the counter while breastfeeding are unsafe for the baby. Laura is continuing with prenatal vitamins but is taking no medications. Diet: Laura is continuing with every‐2‐hour breastfeeding. She tried to pump milk to provide time for bottle feeding when Jake was first discharged from the hospital, but experienced trouble obtain-ing more than 1 oz. of pumped milk in total at a time, which she didn't believe was enough for his supplemental increased calorie bottles. She decided to nurse Jake every 2 hours through the night, since he is an avid feeder. She is not supplementing feedings with fortified formula at this time, since she felt it affected her milk supply to not be nursing every 2 hours. Laura is unsure if she misses any of her own meals because Jake's care is so absorbing, and Laura feels she has no time to herself to care for her own needs. Elimination: Jake has small amounts of yellow loose stools with most feedings, and has about 8-10 wet diapers/day. Sleep and feeding behavior: Jake is difficult to awaken for the frequent feedings, falls asleep during feedings, and mostly sleeps when not feeding. When awake he can be difficult to comfort even to latch on for feeding, but once latched on will settle well into the feeding. If Jake is fussy Laura tends to offer the breast more often than the recommended 2 hours. Jake nurses 10 minutes on one breast and 30-50 minutes on the other breast. He requires frequent stimulation to remain awake during feedings. Family medical history: Both parents are in good physical health. Craig has seasonal allergies, but no history of chronic respiratory problems. Both parents are of average height and weight by report. Neither Craig nor Laura are smokers, nor do they allow Jake near smokers. The maternal grandparents are in their 80s, with a history of heart disease, Type 2 diabetes, and arthritis. The paternal grandparents are in their late 70s, with a history of arthritis, hypertension, and hyperlip-idemia. There is a history of breast cancer in paternal extended family members, and seasonal allergies in both maternal and paternal extended family. Medications: Jake was given his first dose of Hepatitis B (Hep B) vaccine upon hospital discharge. He has had no other immunizations, nor is he currently taking any medications. Allergies: No known allergies. No untoward reaction to the Hep B vaccine. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Postpartum Depression 237 OBJECTIVE General: Jake appears very small for his age. He sleeps quietly during the visit until being undressed for the weight check. Once becoming fussy he is difficult to comfort, and seems to resist cuddling, arching away and escalating rapidly in his distress, which Laura says is typical for him. Throughout the appointment Laura has a noticeably flat affect. She vacillates between a passive posture often looking off out the window and not observing the baby during the exam, to reacting with anxiety, especially as he becomes inconsolably fussy. Vital signs: Jake's temperature is 36. 3°C, AP is 110, R is 40, BP is 50/40. Measurements: Weight 5 lbs. (<5th percentile), head circumference 33 cm (< 10th percentile), and length 18. 5 inches (10th percentile). Skin: Pink, some sagging skin still on his thighs, with some flaking skin, lips moist, good skin turgor, occasional milia on his facial cheeks and nose. Nose: Clear, no discharge. Mouth: Palate intact, some white patches on left side of his mouth, easily removed with a cotton swab. Abdomen: Soft, small, easily reducible umbilical hernia. Cardiorespiratory: Chest clear, no murmurs. Genitourinary: Circumcised, testicles descended, normal urine stream observed. Neurologic: Movements smooth, symmetrical. Poor state control moving from active sleep to full‐out crying. Jake does not respond readily to the usual comfort measures such as holding, position changes, or walking while softly bouncing or rocking. Somewhat hyperactive Moro reflex, strong sucking and rooting, and asymmetrical tonic neck reflexes present. Two‐beat ankle clonus is noted bilaterally. He can be brought into the quiet alert state slowly. Once he calmed, he fixed on a bright red ball and visually tracked the ball 180 degrees. He was attentive to his mother's voice briefly. No vocalizations were heard this appointment aside from fussing, but Laura stated she has heard the beginnings of some cooing recently. CRITICAL THINKING What is the diagnosis and its contributing factors? For Jake For Laura Why must concerns about Laura be addressed at this appointment?What additional information is needed?What are the treatment options? For Jake For Laura What are the plans for referral and follow‐up care? Include resources that may be needed to determine treatment options. What demographic characteristics might affect this case?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
239 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Jonathan is a 28‐year‐old single Caucasian male who works as a systems analyst for a financial services company. He presents complaining of a tense and irritable mood that has worsened in the past few weeks. He also reports feeling anxious and having trouble sleeping. He notes having more frequent headaches, stomach upset, and diarrhea. He often feels tired and complains of difficulty concentrating at work. He worries that his new boss will notice that he's more for getful and taking longer to complete projects. He enjoys his work, but also finds it stressful. He has difficulty unwinding in the evening unless he has a couple of beers, which has become a regular occurr ence. Past medical history: Jonathan reports a history of anxiety that first emerged in high school and recalls worrying needlessly about being late with assignments, disappointing his parents, and losing important friendships. He has no history of treatment for anxiety or other psychiatric disorders. Family history: Jonathan's father has untreated anxiety. His mother has hypertension and diabetes mellitus Type 2. Social history: Jonathan lives with a roommate; they have a good relationship. He has a group of friends and usually sees them on weekends to watch sports. Jonathan is close to his parents and younger sister, who live out of state. He completed a graduate degree 1 year ago and has been employed in financial services for 1 year. He admits to no regular exercise and drinks 2-3 beers daily in the evening. His caffeine intake is 2-3 twelve‐ounce Red Bull energy drinks per day. He denies using other substances. Medications: None. Allergies: No known allergies. Case 9. 4 Anxiety By Sheila Swales, MS, RN, PMHNP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
240 Mental Health OBJECTIVE General: Cooperative, in no apparent distress. Vital signs: BP: 126/82; P: 84; R: 22; T: 98. 6°F; height: 5 ft 11 inches; weight: 188 lbs; BMI: 26. 2. HEENT/Neck: There is no JVD. Cardiovascular: There is a 2+ carotid, no bruit. Regular rate and rhythm, S1 and S2. Respiratory: Lungs are clear to auscultation and percussion. Musculoskeletal: Full range of motion of the neck and trunk. Abdomen is soft, nontender, and nondistended. Extremities show no edema, clubbing, or cyanosis. CRITICAL THINKING What are the top three differential diagnoses in this case and why? Which diagnostic tests are required in this case and why?What are the concerns at this point?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat him?What if the patient lived in a rural (or urban) setting?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
241 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Brittany is a 12‐year‐old biracial female in the 7th grade. She presents twice in 1 week to the school‐based health center (SBHC) for stomachaches. At the second visit, in a discussion about nutrition and sleep hygiene, Brittany reports difficulty with falling asleep due to being worried something bad will happen, especially to her mom, as well as disrupted sleep due to nightmares. Brittany reports her family moved homes 3 months ago because “stepdad is gone and isn't allowed around us anymore. ” After the move, Brittany states “I thought I would feel better, but I felt worse instead. ” She quit gymnastics because it did not feel fun anymore. She also reports difficulty focusing, which has had a negative impact on her grades. The school counselor also reports recent concerns relating to Brittany's concentration and her leaving the classroom frequently for breaks. Brittany acknowledges difficulty focusing and that “my mind won't stop when a room is quiet, so I try to distract myself. ” When asked about her thoughts during those times or the content of her distressing dreams, Brittany quietly says “I'm not ready to talk about it. ” Her school counselor also notes some recent social isolation and an increasingly more serious nature, and comments that this is a shift for a once “smiley and engaging” student. Past medical history: Brittany has a past history of gastroesophageal reflux disease (GERD), which has resolved; she no longer takes medications. She denies any history of prior hospitalizations or surgery. She has seen a gastroenterologist in the past but otherwise does not see any specialists nor does she see her primary care provider regularly. She denies any recent weight gain or loss. She denies sexual activity and had a negative PHQ‐9 and CRAFFT as part of her annual screening at the SBHC. Family history: Her family history is positive for maternal alcohol use and a first‐degree relative with a history of substance use. Paternal history is unknown. Social history: Brittany is the oldest of 2 siblings, both sisters. Her biological parents divorced when she was 3 years old and her biological father lives several states away. He visits on holidays and occasionally in the summer. Her mother remarried and is currently in a domestically violent relationship with Brittany's stepfather. All 3 children witnessed ongoing physical and verbal abuse toward the biological mother. As of 3 months ago, Brittany's stepfather is currently in prison with a no contact order in place for all of the children. Case 9. 5 Trauma By Erin Patterson Janicek, LCSW, and Anna Goddard, Ph D, APRN, CPNP‐PC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
242 Mental Health Sleep history: She reports difficulty initiating sleep and waking throughout the night. She gets an average of 6-7 hours nighttime sleep, per self‐report. She will sometimes take a Tylenol PM from the medicine cabinet to help fall asleep but reports it “doesn't help her stay asleep. ” Medications: None. Allergies: No known drug allergies. Review of Systems:Constitutional: Lack of energy, no weight gain or loss. HEENT: Reports no changes in hearing or vision, no runny nose, postnasal drip, or any URI symptoms. Skin: No itching, dry skin, or rashes. Cardiovascular: No chest pain, no history of cardiac anomalies, no murmurs. Respiratory: No shortness of breath or difficulty breathing, no night sweats, no wheezing or history of RAD. Gastrointestinal: No nausea, vomiting, or diarrhea/constipation. Occasional heartburn with certain foods. Genitourinary: Unremarkable. Musculoskeletal: No join pain or muscle pain. Neurological: Frequent headaches, no double vision, no balance issues, or dizziness. Hematologic: Denies bruising or easy bleeding. OBJECTIVE General: Well‐appearing with age‐appropriate clothing and good hygiene; initially shy but now more talkative. Vital signs: T: 98. 3°F; heart rate: 68; blood pressure: 110/68; RR: 18; height: 5 ft 4 inches; weight: 169 lbs; BMI: 29. Eyes: PERRLA, EOM intact, dark circles under eyes. ENT: Normal appearance of posterior oropharynx, nares patent, no postnasal drip, TMs gray pearly and visible ossicles. Lymph: No lymphadenopathy. Cardiovascular: No JVD, no carotid bruits, no murmurs, regular rate and rhythm, femoral pulses equal +2. Lungs: Clear to auscultation bilaterally, no accessory muscle use, no crackles or wheezes. Skin: Unremarkable. Abdomen: Normal bowel sounds, abdomen soft and nondistended, no HSM. Genitourinary: Not examined. Musculoskeletal: Full range of motion in all 4 extremities. Neurological: Alert and oriented × 3, CN 2-12 grossly intact. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Trauma 243 CRITICAL THINKING What are the most likely differential diagnoses in this case and why? __Post‐traumatic stress disorder__Unspecified trauma‐ and stressor‐related disorder__Child‐affected by parental relationship distress__Major depressive disorder__Generalized anxiety disorder__Hypothyroidism Which diagnostic tests are required in this case and why? __PHQ‐9__Beck Depression Inventory__The Non‐Suicidal Self‐Injury Assessment Tool (NSSI‐AT)__Columbia-Suicide Severity Rating Scale (C‐SSRS Screener)__CBC with differential__Thyroid panel__CMP What are the c oncerns at this point? __Suicide risk assessment __Self‐harm risk assessment__Safety of going home__Headaches__Sleep hygiene__Hypothyroidism What is the plan of treatment?What is trauma‐informed care?What are the plans for referral and follow‐up care?What demographic characteristics might af fect this case? Does the patient's psychosocial history impact how you might treat her?If this patient were male (instead of female), how might that change management and treatment? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 10 The Older Adult Case 10. 1 Forgetfulness 247 By Amy Bruno, Ph D, RN, ANP-BC Case 10. 2 Behavior Change 251 By Sheila L. Molony, Ph D, APRN, GNP-BC, FGSA, F AAN Case 10. 3 Tremors 255 By Amy Bruno, Ph D, RN, ANP-BC Case 10. 4 Weight Gain and Fatigue 259 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 10. 5 Visual Changes 263 By Millie Hepburn, Ph D, RN, ACNS-BC, SCRN Case 10. 6 Back Pain 267 By Ivy M. Alexander, Ph D, APRN, ANP-BC, F AANP, FAAN Case 10. 7 Acute Joint Pain 273 By Sara Smoller, RN, MSN, ANP-BC Case 10. 8 Itching and Soreness 275 By Sheila L. Molony, Ph D, APRN, GNP-BC, FGSA, F AAN Case 10. 9 Knee Pain 277 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 10. 10 Hyperthermia and Mental Status Changes in the Elderly 279 By Suellen Breakey, Ph D, RN, and Patrice K. Nicholas, DNSc, DHL (Hon), MPH, MS, RN, NP-C, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
247 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Sophie is a 62‐year‐old female who presents today with her son, Taylor, for a chief complaint of “forgetfulness. ” Sophie is somewhat withdrawn during the appointment and offers very little information. She gives her son permission to share her history. Her son Taylor tells you that for the past 2 months he has noticed that his mother is becoming increasingly forgetful and more withdrawn. She has forgotten appointments and to pick up her grandson at school 4 times over the past 2 months. She previously was able to take her medications independently but now her son notes he has to remind her daily and has started to organize her medications for her. Taylor also notes that his mother is not sleeping well and is up at 4 a. m. most mornings and then will nap for about 4 hours during the day. She has also stopped going to her weekly knitting group and is not participating in weekly meetings at her church anymore. Sophie does admit today to feeling “down” and simply states, “I don't feel like doing anything. ” She attributes her forgetfulness to being “stressed out” about her daughter and her father's medical condition. She reports she has frequent nighttime wakening because “I worry about my family and my legs hurt. ” When asked how often she is taking her prescribed Alprazolam, she states, “I have to take it 2-3 times a day for my nerves. ” Sophie has not had any trouble getting dressed, making meals, or showering independently. She has not gotten lost with driving. Sophie does not have a mental health counselor or a psychiatrist at the present time. Her former psychiatrist retired 2 years ago and her PCP has been prescribing her psychiatric medications. Past medical history: Type 2 diabetes mellitus, diabetic peripheral neuropathy (DPN), hyperten-sion, hyperlipidemia, depression, anxiety, post‐traumatic stress disorder, chronic insomnia Family history: Mother age 82: Coronary artery disease (CAD), T ype 2 diabetes mellitus, hypertension, hyperlipidemia Father, age 88: Hypertension, hyperlipidemia, pr ostate cancer, diagnosed with Alzheimer's dis-ease at age 80 Brother, age 66: Hypertension, myocardial infarction (MI) at age 65, Type 2 diabetes mellitus Case 10. 1 Forgetfulness By Amy Bruno, Ph D, RN, ANP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
248 The Older Adult Son, age 40: Hypercholester olemia Grandson, age 10: Asthma Social history: Lives with her son, Taylor, and her 10‐year‐old grandson, Joseph, in a suburban house. Taylor assists Sophie with her medications and appointments. T aylor is 40 years old and works full‐time as a math teacher at the local high school. He is divorced and has full custody of his son, as his ex‐wife has a substance use disorder and is currently incarcerated. Retired (worked as a r eceptionist for a dental office for over 40 years). Highest education completed: high school. Divorced for over 10 years and ex‐husband physically and emotionally abused her for over 20 years; ex‐husband now deceased due to lung cancer. Her daughter, Cynthia, has a substance‐use disor der and a history of homelessness and incarceration. No history of smoking or illicit drug use, and she does not drink alcohol. Medications: Metformin 1000 mg po twice daily Gabapentin 1200 mg po three times daily Lisinopril 20 mg po daily Rosuvastatin 20 mg po daily Citalopram 20 mg po daily Buproprion XR 150 mg po bid Alprazolam 0. 5 mg three times daily PRN Trazodone 400 mg po at night Allergies: Sulfa: rash OBJECTIVE General: 62‐year‐old female, well‐dressed, well‐nourished, in no apparent distress. Vital signs: Blood pressure: 136/82; HR: 72; RR 20. Cardiac: AP RRR, no murmurs, rubs, gallops, no JVD, no carotid bruits bilaterally. Pulmonary: Lung sounds clear to auscultation bilaterally, no use of accessory muscles Neurological: Patient is alert/oriented to person, time, and place; flat affect and depressed mood; has difficulty maintaining eye contact during exam; poor effort during physical exam and screen-ing questionnaires; normal insight and judgment, speech clear. CN II-XII grossly intact. Normal tone to all 4 extremities; no cogwheel rigidity noted. Reflexes: 2+ bilaterally to biceps, triceps, and brachioradialis, hypoactive bilateral knee and Achilles reflexes; no clonus, toes downgoing bilat. Coordination: F‐N‐F testing WNL, RAM WNL, Romberg negative. Sensory exam: Decreased pin-prick, light touch, and vibratory sense to lower extremities in a stocking‐like distribution; propri-oception intact. Gait: Slightly wide‐based, normal speed, stride, and arm swing intact, no ataxia observed. Montreal Cognitive Assessment (Mo CA) Screening = 22Patient Health Questionnaire‐9 (PHQ‐9) = 15 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Forgetfulness 249 CRITICAL THINKING What are the top three differential diagnoses in this case and why? Which diagnostic tests are required in this case and why? __CBC__TSH__Vitamin B12__CMP__RPR or FTA testing__Hg A1C__Lipids__ESR What are the concerns at this point?What are 3-5 case‐specific questions to ask the patient?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat her? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
251 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Antonio is an 84‐year‐old male resident of a continuing care retirement community (CCRC). The residential director admitted him to the respite care wing of the nursing home last evening due to behavior changes including agitation, disorientation, and wandering outside without appro-priate clothing. The director brings him to the on‐site clinic the next morning. She reports that the on‐call provider last evening ordered 1 mg of IM haloperidol, which was given soon after the resident came to the unit. The residential director reports that Antonio had a poor appetite for a few days before this and was found napping in the lounge, which is not unusual. He fell on his way to the dining room the previous morning, but sustained no apparent injury. During his last annual health maintenance visit 3 months prior, he scored 22/30 on the Montreal Cognitive Assessment (Mo CA) and was diagnosed with mild cognitive impairment (MCI). He is usually alert and oriented to season, year, place, and person and has no difficulty navigating inside or outside his residence. His only complaint today is a new complaint of frequent heartburn that he has been treating with over‐the‐counter (OTC) pills (he can't remember the name). He denies pain, cough, shortness of breath, or changes in bladder/ bowel habits. Past medical history: Coronary artery disease (CAD) with angioplasty/stent placement ×2, hyper-tension (HTN), benign prostatic hypertrophy (BPH), asthma, hyperlipidemia (HLD), heart failure with normal ejection fraction (HFNEF), mild cognitive impairment (MCI), osteopenia, and osteo-arthritis (OA). He had a motorcycle accident in his youth with a left leg injury. Psychosocial history: Antonio moved to the CCRC 1 year ago with his wife, who died 4 months prior. He cared for her until she died, then stayed in his apartment, complaining of anxiety and difficulty sleeping. He recently became more involved in community activities and has been making friendships in the building. He has been attending two meals per day in the communal dining room, until this week, and has been independent in bathing, dressing, grooming, walking, transferring, eating, and toileting. He does not climb stairs due to poor endurance but is able to walk on level ground over modest distances without fatigue. Before his wife died, he would take the community van to local shops twice a month. He has a daughter‐in‐law and two nieces who live within 50 miles, call weekly, and visit once or twice a month. Case 10. 2 Behavior Change By Sheila L. Molony, Ph D, APRN, GNP‐BC, FGSA, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
252 The Older Adult Medications: Fluticasone propionate 100 mcg/salmeterol 50 mcg (Advair Diskus), one inhalation twice per day; simvastatin, 40 mg by mouth, once daily; atenolol, 100 mg by mouth, once daily; losartan, 50 mg by mouth, once daily; furosemide, 20 mg by mouth, once daily; K‐dur, 10 m Eq by mouth, once daily; isosorbide mononitrate ER (Imdur), 30 mg by mouth, once daily; alendronate, 70 mg once per week; multivitamin (MVI) with iron, 1 by mouth, once daily; vitamin C, 500 mg by mouth, twice daily; docusate sodium succinate, 1 by mouth, once daily; OTC medication ‐unknown for heartburn. Allergies: NKDA. Health maintenance: Td vaccine 2007. Never had the flu vaccine, pneumococcal vaccine, or shin-gles vaccine (received education/information on last visit). OBJECTIVE Vital signs: Temperature: 100. 0°F; pulse: 58 (irregular); respirations: 28; blood pressure: 168/58; weight: 161 (164 last month); height: 72 inches. Note: His usual vital signs are: Temp: 97. 4°F; pulse: 70-80 (regular); BP: 130-140/60-70). General: Today Antonio appears sleepy, disheveled, restless, and vague. He can walk to the exami-nation room but is unsteady and needs assistance getting undressed for the physical examination. He is unable to fully cooperate with the exam. His skin is dry, especially over the lower extremities. Mental status: Speech is slow but clear; thought processes are slow and disorganized; irritable mood; distractible; decreased ability to focus. MOCA15/30. Head: Normocephalic without obvious lesions, masses, depressions, or tenderness. No temporal bruits. Eyes: Visual acuity 20/40 bilaterally with glasses. Eyelids are symmetrical with no ptosis, but slight ectropion bilaterally. PERRLA. Conjunctiva and sclera clear with slight arcus senilis. EOMs and visual fields WNL with slight decrease in upward gaze bilaterally. He has a few beats of horizontal nystagmus on extreme lateral gaze. Red reflexes intact but incomplete visualization of retinas due to difficulty cooperating with exam and frequent eye closing/sleepiness. Ears: Unable to cooperate with hearing acuity screen. External ears are without lesions or tender-ness. Canals are obstructed with dark cerumen bilaterally. Unable to visualize TMs. Nose/sinuses: Nares patent with pink mucosa; no lesions, deviations, or discharge. No frontal or maxillary sinus tenderness. Mouth/throat: Oral mucosa dry and intact. Tongue and uvula midline, and tongue movement is symmetrical. Pharynx clear. No lesions, masses, cavities, or bleeding. Neck: Supple; no carotid bruits or thyromegaly. No cervical lymphadenopathy. Chest: No skin lesions, deformities, tenderness, crepitus, axillary lymphadenopathy, or breast masses. No rubs or thrills. PMI nonpalpable. Heart: Regular rhythm with frequent pauses. No murmurs or obvious gallops. Lungs: Symmetrical chest wall expansion. Resonance on percussion throughout all fields. Fremitus palpable and symmetrical. Fine crackles at left base, and coarse inspiratory crackles | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Behavior Change 253 and expiratory rhonchi over right lower lung field. No egophony, bronchophony, or whispered pectoriloquy. Abdomen: Soft, nontender, with quiet bowel sounds in all quadrants; no palpable masses, organomegaly, or bruits. Soft stool in rectum; hemoccult negative. Slightly enlarged prostate, symmetrical. No palpable masses. Neurologic: Gait shuffling with small steps. Slightly unsteady, leaning to one side. Unable to stand with feet together without swaying. No pronator drift. No postural or intention tremor. CNs II-XII grossly intact. Reflexes 3+ and symmetrical in both upper extremities. Lower extremities: 2+ patellar reflex, 1+ Achilles reflex. Plantar reflex ↓. Able to detect pain in all extremities, but unable to cooperate with full sensory or coordination testing. Musculoskeletal: Muscle strength 4/5 in upper and lower extremities bilaterally. Peripheral vascular: Bounding radial and brachial pulses: 2+. Femoral and popliteal: 2+. Pedal: 1+. Unable to detect posterior tibial pulse. Ankle edema bilaterally with left > right: 2‐3+. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Head CT or MRI___Chest X‐ray___Abdominal X‐ray___Urinalysis___EKG___CBC with diff___Complete metabolic panel (includes: albumin, blood urea nitrogen, calcium, carbon, chloride, creatinine, glucose, potassium, sodium, total bilirubin and protein, and liver enzymes___Ammonia level___Arterial blood gas or pulse oximetry___TSH, free T4, T3___Toxic screen of blood or urine___Orthostatic blood pressure___Depression screening___Rapid plasma reagin (RPR)___HIV___B12/folate___Lumbar puncture___Electroencephalogram (EEG)___Cultures (urine, sputum or blood) Which differential diagnoses should be considered at this point? __Dementia__Depression__Delirium__CVA/TIA__Psychiatric/mental health condition | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
254 The Older Adult What is the treatment plan? Are any referrals needed?What aspects of the health history require special emphasis in older adults?What if this patient were under age 65? Would that change the management plan?What patient, family, and/or caregiver education is important in this case?Are there any standardized guidelines that should be used to assess or treat this case?What are some of the possible contributors to this patient's hypotension? Are any referrals needed? What management strategies should be considered? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
255 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Mr. Alfredo Suarez is a right‐handed 68‐year‐old male who presents to the office with tremors to bilateral hands. His daughter, Maria, accompanies him to this visit and is worried he has “Parkinson's. ” Mr. Suarez reports that he first noticed “shaking” to his hands about 2 years ago but was not both-ered by it and attributed it to “getting old. ” Over the past 2 months, the hand shaking has started to interfere with his ability to play cards and prepare meals. Maria interjects and states “his hands shake all the time now and he can't even hold a fork. ” Maria goes on to report that her father is an avid woodworker and is no longer working in his shop because he kept “dropping tools. ” Mr. Suarez states the tremors are consistently present all of the time and he most notices them when he tries to hold objects or read his book. He is most annoyed by these symptoms because they are interfering with hobbies. He reports, “people notice it and bring it up and then it gets worse. ” He says that his brother has “shaky hands” and that he thinks his paternal grandmother had “Parkinson's” because “she always shook. ” He reports that tremors increase during stress and anxiety. He reports he also feels “more anxious lately” and doesn't know if his medication is working. He notes increased anxiety about attending social events and worrying about his grand-daughter, who was diagnosed with epilepsy last year. He feels his hands are becoming “very clumsy. ” He denies any alleviating factors. He denies any numbness or weakness to extremities. Denies any changes in gait or falls. Past medical history: Hypertension (HTN), hyperlipidemia (HLD), generalized anxiety disorder, GERD, asthma/COPD overlap syndrome Family history: Mother: HTN, HLD, CAD Father: Stroke, HTN, T ype 2 DM Brother: HTN, T ype 2 DM, “shaky” hands Social history: Patient is widowed and lives alone. He lost his wife 2 years ago due to breast cancer. He has 1 daughter, Maria, and 2 grandchildren who he sees regularly and who live nearby. He retir ed at age 65 and worked as a carpenter. Case 10. 3 Tremors By Amy Bruno, Ph D, RN, ANP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
256 The Older Adult Hobbies: Woodworking, cooking, spending time with family, and reading. Nonsmoker; no illicit drug use. Drinks a “shot” of bourbon 3-4 nights per week. Medications: Lisinopril 20 mg po daily Rosuvastatin 20 mg po daily Fluoxetine 60 mg po daily Omeprazole 20 mg po daily Albuterol MDI 2 puf fs every 4 hours as needed Tiotr opium inhaler 2 puffs once a day Allergies: NKDA OBJECTIVE General: Pleasant, cooperative, NAD. Vital signs: BP: 142/88; HR: 72; RR: 20; T: 98. 9°F; height: 72 inches; weight: 210 lbs; BMI: 27. Systems approach listed by system:Cardiovascular: Apical pulse RRR, no murmurs, rubs, gallops, no S3, S4. Pulmonary: Lung sounds clear to auscultation bilaterally; respirations unlabored and regular. Musculoskeletal: FROM to all 4 extremities, normal muscle bulk noted, no edema, redness to joints, strength 5/5 to all 4 extremities. Neurological: Patient is alert/oriented to person, time, and place; normal affect and mood; normal insight and judgment, speech clear. CN II-XII intact. Normal tone to all 4 extremities; no cogwheel rigidity noted. Reflexes: 2+ bilaterally to biceps, triceps, and brachioradialis, 1+ to bilateral knees and Achilles; no clonus, toes downgoing bilaterally. Coordination: F‐N‐F testing WNL, RAM WNL, Romberg negative. Sensory exam: Normal pinprick, light touch, and vibratory sense to all 4 extrem-ities; proprioception intact. Tremor exam: Bilateral course action and postural tremor noted to both hands that relieves at rest, right is slightly more prominent than left; there is no intention or resting tremors on exam; no other adventitious movements noted. Spiral drawing, done with right hand. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Tremors 257 Gait exam: Patient able to arise from a sitting to standing position without using arms; demon-strates normal speed, stride, and turn, arm swing intact bilaterally, slightly stooped posture, no reemergence of hand tremors with ambulation. CRITICAL THINKING What are the top three differential diagnoses in this case and why? Which diagnostic tests are required in this case and why?What are the concerns at this point?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat him?What if the patient lived in a rural (or urban) setting?Are there any standardized guidelines that should be used to treat this case? If so, what are they?Are there other history questions that are pertinent when assessing a patient with tremors?If this patient did not have insurance, would that change the management strategy? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
259 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Maxwell is a 70‐year‐old homosexual African American male and retired corporate lawyer who first came to the health maintenance organization 3 years ago. At that time, he had not been to a primary care provider since he retired from full‐time work at age 60. Maxwell continues to consult and does occasional part‐time work for his previous law firm. He admits to a sedentary lifestyle, a weight gain of 25 pounds within the past 2 years, and occasional fatigue and headache. Past medical history: None significant. Past surgical history: Significant for a tonsillectomy at the age of 7. Family history: Significant for thyroid disease, hypertension, coronary artery disease, Type 2 diabetes mellitus, hyperlipidemia, and obesity. Father died from a myocardial infarction at age 69. OBJECTIVE VISIT THREE YEARS AGO Vital signs: 220 lbs with a height of 6 ft 1 inch and a body mass index of 29. Blood pressure: 140/88; radial pulse: 78; temperature: 98. 7°F; respiratory rate: 16. Physical examination: Significant for acanthosis nigricans and central adiposity. Diagnostic test results: Fasting lipids revealed a total cholesterol of 182, a low‐density lipoprotein level of 106, a high‐density lipoprotein level of 57, and a triglyceride level of 95. His fasting blood glucose was 95, and the Hemoglobin A1c was 5. 6. His thyroid‐stimulating hormone level was 8. 0 m U/L. A routine electrocardiogram documented normal sinus rhythm and rate. Diagnoses: Hypertension and hyperthyroid disease. Case 10. 4 Weight Gain and Fatigue By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
260 The Older Adult Plan: The patient is started on hydrochlorothiazide 25 mg, aspirin 81 mg, and Norvasc 2. 5 mg by mouth daily and levothyroxine 0. 50 mcg by mouth daily. He is counseled regarding lifestyle modifications, inclusive of preparing and eating a low‐sodium and low‐fat diet. Maxwell was encouraged to start a routine exercise program of at least 30 minutes of modest aerobic activity such as walking as if to catch a bus. He was also encouraged to lose 5-7% of his body weight. These lifestyle modifications have proven effective in diabetes prevention and maintenance, as well as in control of blood pressure and lipid levels. The patient is informed regarding the mechanism of action of the medications, duration of action, contraindications, and adverse effects. The patient is also instructed to take the levothyroxine on an empty stomach first thing in the morning. THREE‐MONTH FOLLOW‐UP VISIT Vital signs: Blood pressure of 128/76. Diagnostic test results: Thyroid‐stimulating hormone level is 4. 50. Basic metabolic panel: blood urea nitrogen level of 14; creatinine level of 0. 98; sodium level of 137; potassium level of 3. 8; and a chloride level of 104. Plan: The patient was given a list of potassium‐containing foods and reminded to eat 1 or 2 items daily due to his low potassium level. He is instructed to continue to take his medications. TODAY'S VISIT SUBJECTIVE Maxwell has been very busy in his semi‐retirement and has not been in for a physical examination or labwork for more than 2 years. Now he presents with complaints of extreme fatigue for the past 2 months and low libido. He states that he feels fatigued all the time, and sleep does not seem to relieve it. He is able to work around the house, but has cut back on his legal work and has limited socialization and participation in outside activities due to fatigue. He reports sleeping for 8-10 hours a night, with his sleep interrupted by a need to go to the bathroom at least twice. He awakens fatigued. Sexually, he has a morning erection but not as strongly as in previous months. He has limited sexual desire. He is able to have an erection with intercourse, but it is less of an erection than pre-viously. He states that he has been in a monogamous relationship for the past 2 years. He admits to a 15‐pound weight gain over the past 2 years. He reports that he experiences occasional consti-pation and some cold intolerance. He reports feeling “shaky” on occasion, especially when he has not eaten in a while. He denies fever, night sweats, and tobacco or drug use and reports socially drinking several glasses of red wine per week. Past medical history: Remains significant for hypertension and hypothyroidism. Past surgical history: Remains the same. Family history: Unchanged. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Weight Gain and Fatigue 261 Medications: Hydrochlorothiazide 25 mg by mouth daily, Norvasc 2. 5 mg by mouth daily, levothy-roxine 0. 50 mcg by mouth daily, aspirin 81 mg by mouth daily, multivitamin, 1 capsule and fish oil capsules, 2000 mg by mouth daily. There are no known drug allergies and no known food allergies. OBJECTIVE Vital signs: Temperature: 98. 6°F; radial pulse: 76; blood pressure: 134/80; oxygen saturation: 99%; height: 6 ft 1 inch; weight: 235 lbs (15‐lb weight gain); body mass index: 31. Physical exam is unre-markable except for the following findings: Skin: Poor skin turgor; acanthosis nigricans. Mouth: Dry oral mucosa. Cardiac: NSR, No ectopy. Respiratory: CTA bilaterally. Abdomen: Central adiposity. Lymph: No significant lymphadenopathy. Rectal: Hemoccult negative for occult blood. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis? ___FIT test___Complete blood count___Thiamine___Iron studies___Complete metabolic panel___Rapid HIV test___HIV viral load test___Hb A1c___Thyroid‐stimulating hormone___Testosterone___Urine analysis___Tuberculosis testing___Urine microalbumin/creatinine ratio___FSH and LH___Prolactin___Chest X‐ray What is the most likely differential diagnosis and why? ___HIV and/or AIDS___Pernicious anemia___Hypothyroidism uncontrolled___Secondary hypogonadism___Diabetes mellitus | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
262 The Older Adult What is the plan of treatment? What is the plan for referrals and follow‐up?Does the patient's psychosocial history impact how you might treat him?What if this patient were a premenopausal female?What if the patient were over the age of 80?Are there standardized guidelines that should be used to assess and treat this patient? NOTE: The author would like to acknowledge the contribution of Vanessa Jefferson, MSN, BCANP, CDE to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
263 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Marion is an 85‐year‐old woman of European descent who lives alone and comes to the office every 3-6 months for monitoring of hypertension and hyperlipidemia. Today she presents with a concern about vision changes. Marion reports some vision changes including increased sensitivity to glare; increased difficulty with dark adaptation, with colors seeming not as vivid as they used to; and increased difficulty with reading, but that she does not have any “floaters” as her friend reported to her last week. She states that she needs bright light to read comfortably. She mentions that this has worsened over the past few years and has become increasingly bothersome. She denies any eye pain or discharge, diplopia, or halos. She has no history of eye trauma. She men-tions that her last eye exam was 5 years ago. She denies any history of glaucoma but thinks she may have had some early cataracts on her last exam. Marion states that she maintains an independent lifestyle and requires no assistance in her day to day activities. Past medical/surgical history: Hypertension; hyperlipidemia; peripheral arterial insufficiency; osteoporosis; generalized anxiety disorder; osteoarthritis; status post hip fracture with repair/pinning at age 82. Family history: Mother: died at age 78, lung cancer; had age‐related macular degeneration and migraines. Father: died at age 65, MI; had coronary artery disease, diabetes, and stroke. Social history: Marion was widowed 10 years ago and lives alone in a 1‐bedroom, first‐floor apartment with 5 steep stairs to enter the building. She is dating socially and attends the senior dances at the local community center about once a week. She maintains the flower gardens in her front yard and states that she walks a half mile most days with her friend. Marion states that she falls asleep without difficulty most nights, but often awakens during the night and has difficulty falling back asleep. She states that she actually sleeps about 5. 5 hours per night, but experiences some daytime sleepiness. She states that she has 1-2 drinks after her dance class and occasionally when on a date. She quit smoking 25 years prior (smoked 1 pack of menthol cigarettes per day for 40 years). Diet: Marion's typical diet includes toast with butter and jam for breakfast with black coffee; soup and sandwich with a glass of milk for lunch; roast beef, potatoes with gravy, and green beans with butter and salt for dinner; and no snacks. She eats dinner out with friends about 2 or 3 nights per Case 10. 5 Visual Changes By Millie Hepburn, Ph D, RN, ACNS‐BC, SCRN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
264 The Older Adult week at the diner or a restaurant and usually has some type of meat, potato or white rice, and a cooked vegetable. She does not drive, as she uses public transportation. Medications: She has brought all of her medication bottles with her. Her medications include lisinopril, atorvastatin, citalopram, and alendronate. She has an expired prescription/bottle of hydroxyzine that she states that she uses occasionally for “nerves. ” She also takes acetaminophen as needed for arthritis pain. Allergies: Penicillin (causes rash to chest and arms). Marion admits to some gradual visual changes; difficulty hearing (mostly in crowded restau-rants); postnasal drip; and occasional arthritis pain in her shoulders, fingers, hips, and knees. She admits to occasional leakage of urine when she has a cold/cough. She denies headache, falls, head trauma, cough, dyspnea, chest discomfort, abdominal pain, and change in appetite or weight, polyuria, polydipsia, polyphagia, weakness, numbness, and dizziness. OBJECTIVE Eyes: Visual acuity: 20/40 in both eyes (with corrective eyeglasses). The outer one‐third of her eyebrows is absent. Slight ectropion bilaterally. Conjunctiva/sclera clear. No crescentic shadow. Positive for arcus senilis. PERRLA. EOMs intact with mild decrease in upward gaze; visual fields full. Positive for red reflex bilaterally; suboptimal retinal visualization. The remainder of the physical examination is unchanged since her last visit. CRITICAL THINKING Which diagnostic studies should be considered to assist with or confirm the diagnosis?___Amsler grid___Macu Flow___National Eye Institute Visual Functioning Questionnaire 25___Ophthalmological referral for testing Which of the symptoms or signs related to Marion's eyes or vision represent pathological changes versus normal aging? Which differential diagnoses should be considered at this point? What are the three most common diagnoses/conditions affecting vision in older adults? Are Marion's signs and symp-toms similar to the clinical presentations of these conditions?___Macular degeneration___Glaucoma___CVA___Cataracts Based on this exam, what is the plan of care? Would you seek any referrals from the interpro-fessional team? If Marion were under 65 years of age, would the management plan change?What patient, family, and caregiver education is most important in this case?A few weeks after the visit described above, you receive a phone call from Marion's friend, who calls the clinic with news that Marion experienced a brief episode of slurred speech and | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Visual Changes 265 right‐sided weakness that lasted a few minutes. These symptoms occurred about 30 minutes ago. What is your priority recommendation? Her friend reports that Marion is feeling fine now but she is frightened. What is your advice? What diagnostic evaluation should be completed?What education is needed?What is the management plan?What are some of the most important domains of nursing assessment and management (physical, psychological) during these first few hours after symptoms? In the early post‐stroke period? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
267 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Mary is a 63‐year‐old female who presents with upper midback pain that began after lifting her 3‐year‐old granddaughter 3 days ago. She says the pain began right after she lifted her grand-daughter up over her head and then placed her into the high chair. Her granddaughter weighs about 25 pounds. Mary says she has done this many times without any pain or problems in the past. Mary cares for her granddaughter during the day while her daughter is working. She describes the pain as sharp and notes that it radiates into her lower chest and around to her abdomen. Mary's pain is constant and heavy but does wane a little bit with rest (5-7 on a 1-10 scale). It is unaffected by nonsteroidal anti‐inflammatory drugs (NSAIDs), acetaminophen, or topical rub, each of which she tried once. She feels slightly short of breath, described as “it is hard to take a full breath in, because it hurts. ” She found it difficult to put on a turtleneck shirt this morning. Mary describes her overall health as “good. ” She says that she is enjoying retirement and caring for her granddaughter. She reports stable weight for the past 5-6 years; she had gained 5-10 pounds in the first 2-3 years after menopause. She identifies her usual weight as 120-125 pounds. She reports good energy and that she usually sleeps well but has not slept well since this pain began. She denies any substantive premenstrual syndrome (PMS) symptoms when she was having regular menses. She denies having had symptoms of premenstrual dysphoric disorder (PMDD). Mary reports her usual mood as “excellent!” Mary denies moodiness, nervousness, anxiety, irritability, or feeling quick to anger. She denies feeling depressed and says, “I laugh a lot. I have loads of fun caring for my granddaughter, and my husband is always quick with a joke. ” Mary denies anhedonia and says that she enjoys gardening, reading, and social activities with her husband, friends, and daughter and her family. Mary denies eating disorders. She says she has had to reduce her intake lately to keep her weight stable. Mary denies problems with concentration, memory, or cognition. She says she uses a calendar to keep track of activities, especially appointments or play dates and preschool for her grand-daughter. Mary reports no specific systemic complains. She denies general fatigue and says she did not have terrible hot flashes like her sister did with the change of life. She feels well. Case 10. 6 Back Pain By Ivy M. Alexander, Ph D, APRN, ANP‐BC, FAANP, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
268 The Older Adult HEENT: Mary denies problems with headaches. However, she has sinus headaches when her seasonal allergies are bothersome. Mary uses bifocals, which she has had for many years. She has annual ophthalmologic exams with her optometrist. She denies changes in hearing, smell, taste, or swallowing. She reports some dry‐eye symptoms and needs to use eye‐lubricating drops only rarely. She has seasonal allergies that cause light rhinorrhea, sneezing, and itchy eyes in the fall. Respiratory: Mary denies cough or wheeze. She describes a sensation of being short of breath since the pain began, saying, “It is not that I can't breathe; it is that I cannot take in a full, deep breath because it hurts. ” Cardiovascular: Mary denies prior chest pain, palpitations, dyspnea on exertion (DOE), peripheral edema, or a history of blood clots. She says that the pain she has now radiates into her lower chest but is definitely coming from her upper midback area. She denies problems with cold hands and feet. She reports being diagnosed with high blood pressure about 8 years ago. She has been treated with HCTZ, which she tolerates well. Breast: Mary reports that she does regular self-breast exams. She usually does them at the beginning of the month when she changes the calendar to the new month. She denies any concerns or recent breast changes. She denies any discharge, pain, or tingling. She breastfed her daughter. Gastrointestinal: Mary denies heartburn or persistent abdominal pain. She reports daily regular bowel movements, without constipation or recent changes in color, consistency, or pattern of stools. Specifically, she denies seeing any blood or experiencing fecal incontinence. She describes some pain radiating into her abdomen but again states that it is definitely coming from her upper midback. Genitourinary: Mary reports some urgency and occasional leakage of small amounts of urine, especially with coughing or laughing. She denies urinary frequency, history of recurrent urinary tract infections, pyelonephritis, renal stones, and urine dribbling or outright incontinence. She says she does not have dysuria. She reports occasional nocturia of once or twice at night. She says this is usual for her over many years and that she goes right back to sleep after using the toilet. Gynecological: Mary reports no abnormal Pap smears or GYN surgeries. She denies vaginal or vulvar discharge, itching, irritation, soreness, burning, abnormal bleeding, or lesions. She denies pelvic pain or rash. She reports some vaginal dryness, especially noticed with sexual activity. Pregnancy history: Mary has been pregnant twice. She is P2, G1, TAB 1 (for fetal demise at 11 weeks). Her daughter is healthy at age 32. Mary reports that she breastfed her daughter for 13 months. Menstrual history: Mary reports that her LMP was 11 years ago. She reports that her menses were regular, lasting for 6-7 days with 2 days of light flow, followed by 3 days of heavier flow, and then 1-2 days of light flow again. She experienced menarche at 12 years of age; and after the first few years, she had very regular periods occurring about every 28 days. Her menses remained regular right up until her last period. Menopause: Mary reports that her experience with the transition to postmenopause was fairly smooth. She had some hot flashes during the day and rarely at night. She did not experience drenching sweats. She never took hormone therapy or other medications for her symptoms. She has some vaginal dryness, and she and her husband do use lubricant when having sexual intercourse. Contraception: Mary reports that she used oral contraceptive pills for contraception in the past. She stopped using oral contraceptive pills after her last pregnancy; she and her husband used either male condoms or withdrawal after that. She says that she would not have minded getting pregnant again, but it never happened. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Back Pain 269 Sexual: Mary reports that she is sexually active with her husband of 35 years. She is mostly sat-isfied, but she notes that it has become harder to get adequately lubricated and that it takes longer to achieve orgasm. She reports she has had 6 lifetime partners and has been monogamous with her husband for over 38 years. They have intercourse about once a week. She reports that her desire/libido is satisfactory but is less strong than it was when she was younger. She denies dys-pareunia. She reports their usual sexual practices include initiation by her husband, cuddling and kissing, then foreplay that includes genital manipulation, and then vaginal intercourse with penile penetration. They regularly use over‐the‐counter (OTC) lubricants, due to her dryness. She says she feels good during sex and enjoys sex with her husband. She reports their relationship quality as “Wonderful. He is my partner and my best friend. ” She says that, due to the pain in her upper back, she did not engage in sex last night when her husband tried to initiate. Musculoskeletal: Mary reports that she felt good up until 3 days ago. She has had rheumatoid arthritis (RA) for many years, and it is well controlled on her current DMARD (disease‐modifying antirheumatic drug). She has used steroids for about the past 6 years (oral prednisone 5-10 mg daily depending on her symptoms) and then started DMARDs. She now takes a new DMARD, leflunomide; and she has not had a significant flare for a few years with this new medication. She does have some morning stiffness that is mostly relieved with a warm shower and movement. She gets regular exercise and is quite active in caring for her granddaughter with daily walks, often pushing the stroller, getting her in and out of the high chair, and playing with her on the swings at the park. Endocrine: Mary denies polydipsia, polyuria, polyphagia, and symptoms of diabetes mellitus Type 2 (DMT2). Skin/hair: Mary denies any recent skin changes or lesions of concern. She has noticed some increased dryness and wrinkles and dry/thinning hair, especially on her head. She denies hir-sutism or facial hair. Hematologic: Mary denies any bleeding or bruising that doesn't correlate to a specific injury. She says she is a bit surprised that there is no bruising on her back as it feels like there should be something visible. Neurologic: Mary denies numbness, tingling, fainting, dizziness (vertigo), feeling off balance, or difficulty walking. She had some numbness in her right shoulder‐blade region the day after her pain began; that numbness has subsided. Sleep: Mary's usual bedtime routine includes nighttime washing and tooth brushing followed by reading for about 20 minutes. She denies using stimulants except for coffee each morning. She wakes every night to urinate and reports that she falls right back to sleep. Since her back pain began, she has had trouble sleeping. She is able to fall asleep but then awakens in pain and finds it very hard to get back to sleep because she cannot get comfortable. She usually goes to bed around 10 p. m. and falls asleep around 10:30 p. m. She gets up around 6:30 a. m. most days. She reports that she usually feels refreshed when she wakes up but has not since her back pain began. Past medical/surgical history: Rheumatoid arthritis (RA), well controlled at present; history of oral steroid use in the past 6 years; + hypertension, controlled; + seasonal allergies (fall). Wisdom teeth excisions at age 18; TAB at age 33. Family history: Mother: deceased from breast cancer; father: DMT2, HTN, some dementia; sister: A+W. Social history: Mary lives with her husband of 35 years and the family cat in a private home that they own. She is a retired elementary schoolteacher and currently provides day care for her grand-daughter while her daughter works. She reports that she enjoys caring for her granddaughter very | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
270 The Older Adult much and is thrilled that she can help her daughter and son‐in‐law by caring for her grand-daughter. She reports no important recent life events; the most recent was her granddaughter's birth 3 years ago. She describes her usual day as follows: She awakes around 6:30 a. m., makes breakfast for herself and her husband, showers and dresses, greets her granddaughter and pre-pares her breakfast, reads a book with her granddaughter, and then they watch Sesame Street on TV. Some mornings they have a play date or go to the library for reading circle or music. She feeds her granddaughter lunch around noon and then settles her to nap from about 1-3 p. m. In the afternoons they might have a play date, go to the park, read, or play some games at home. Her daughter usually picks up the granddaughter around 5:30 p. m. Mary makes dinner most evenings and spends time in the evening with sewing, TV, playing cards with her husband, or doing household chores. She starts getting ready for bed around 10 p. m. She reports walking for about 1 mile most days with her granddaughter in the stroller. On the weekends she also goes to a water aerobics class. Her 24‐hour diet recall reveals: cereal with 1% milk and coffee (black) for breakfast; tuna salad on toast for lunch; grilled chicken with garden salad for dinner; and carrot sticks for an afternoon snack. She reports that she eats out about once per week and enjoys dessert on occasion. She denies use of tobacco. She reports alcohol use as 1 glass of red wine most evenings. She denies use of recreational/illicit drugs. She reports feeling safe at home and with her husband and family. She denies ever having been hit, slapped, kicked, or otherwise physically hurt by someone (except her granddaughter who occasionally will “fight” when it is time to change clothes). She denies ever being forced to have sexual activities when she did not want to. She uses seatbelts and sunblock regularly and has working smoke and carbon monoxide detectors at home. There are no guns in the home, and she denies any concerns for her granddaughter's or her personal safety. She denies having any current concerns about HIV. Medications: OTC antihistamines for allergies PRN; nasal spray for allergies PRN; MVI daily; calcium (when she remembers); HCTZ, 25 mg daily; glucosamine sulfate with chondroitin, 1500 mg in divided dose daily; omega‐3 supplements (fish oil), 2 g daily; leflunomide, 10 mg daily. Allergies: NKDA, NKFA (but finds that too much yeast bothers her RA with increased morning stiffness and more joint swelling). Some “hay fever” in the fall. OBJECTIVE General: Appears well, but uncomfortable with slow careful movements and limited use of upper extremities; neatly dressed; appropriate affect. Vital signs: BP: 130/78 (L) sitting; P: 74; RR: 10; weight: 130 lb; height 5 feet 5 inches; BMI 21. 6. Neck: Supple, w/o LAN. Thyroid NT, w/o palpable masses or enlargement. Carotids w/o bruits. Limited neck AROM, especially chin‐to‐chest, due to pain. Respiratory: Clear to anterior and posterior; w/o wheezes, rales, rubs, or rhonchi. Patient unwilling to take full inhalation due to pain. Cardiovascular: RRR, normal S1 and S2 w/o murmurs, rubs, or gallops; +pain with manual com-pression to anterior and posterior chest wall. No cyanosis, edema, or clubbing; +2 pulses bilaterally. Breasts: Without masses, skin changes, or discharge bilaterally. No lymphadenopathy. Abdomen: Positive for bowel sounds ×4 quadrants; soft, nondistended. NT with superficial or deep palpation; without HSM, masses, or bruits. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Back Pain 271 Spine: Good AROM at waist and for twisting with lower spine. Thoracic spine with limited AROM due to pain; +tenderness over T7 and T8. Musculoskeletal: Positive for FAROM throughout; but limited upper spine mobility and upper extremities for full overhead movements, slight tenderness and swelling over MCP and PIP joints of BIL hands, joints w/o crepitus, no digital ulnar deviation, no swan neck or boutonniere deformities, no nodules. 5/5 motor strength, but with limited effort of bilateral upper extremities (BIL UEs). Neurologic: CN II-XII grossly intact; gait even; DTRs 2+; Romberg negative. CRITICAL THINKING What are the most likely differential diagnoses in this case and why?Which diagnostic tests are required in this case and why?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat her?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
273 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Rami is a 72‐year‐old male presenting with 2 days of acute onset left great toe pain. He complains of pain with any movement or ambulation. He denies trauma or injuries. He woke up with the pain 2 days ago; it began very suddenly. He denies a prior history of foot or leg problems. He has never had symptoms like this before. Rami reports otherwise feeling well; he denies any systemic symptoms including fever or chills; however, he notes that his toe feels warm. He has been taking Tylenol 650 mg every 6 hours with minimal relief. He tried 2 ibuprofen yesterday that helped slightly. He avoids taking this, as it upsets his stomach. Past medical history: Osteoarthritis, COPD, hypertension. Family history: Rami's mother and father have diabetes mellitus Type 2. His father has severe osteoarthritis. Social history: Rami is a retired nurse. He lives alone; his wife died 3 years ago of pancreatic cancer. He has 4 children; they all live in New York where he is from, originally. Rami is a non-smoker and drinks 2 glasses of red wine nightly. He is fairly active, playing pickleball with the town league 1-2 × per week. Medications: Tylenol 325 mg prn; Spiriva 1 inhalation daily; albuterol 50 mg qd; chlorthalidone 25 mg qd; amlodipine 10 mg qd Allergies: Sulfa (hives) OBJECTIVE General: No apparent distress. Vital signs: Temperature: 97. 9°F (PO); BP: 158/72; pulse: 64 and regular. He is 5 ft 11 inches tall and 195 pounds. General: Rami is pleasant and cooperative and in no distress. Case 10. 7 Acute Joint Pain By Sara Smoller, RN, MSN, ANP‐BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
274 The Older Adult Eyes: PERRL. No injection or icterus. Cardiac: Regular rate and rhythm, no murmurs. Lungs: Clear bilaterally. Abdomen: Soft, nontender, nondistended. No palpable masses or hepatosplenomegaly. MSK: Left great toe swollen with diffuse erythema, warmth, and tenderness to light touch over the metatarsal phalangeal (MTP) joint. Minimal flexion and extension of the great toe due to significant pain. Gait is antalgic due to pain. Pulses: Bilateral dorsalis pedis and posterior tibial pulses 2+. Skin: No rashes to the lower extremities, left great toe is diffusely erythematous. CRITIAL THINKING What is the most likely diagnosis and why? ___Sprain/strain___Acute gouty arthritis___Septic arthritis___Osteoarthritis___Rheumatoid arthritis What are possible differential diagnoses?Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___X‐ray___Complete blood count___BUN/Creatinine (renal function)___Uric acid___Joint aspiration What is the plan of treatment?Are there any modifiable risk factors or medications Rami is taking that could contribute to this diagnosis? What are the plans for referral and follow‐up care?What health education should be provided to Rami at this visit?What if Rami had uncontrolled diabetes mellitus? How would this affect the treatment plan?Rami recovers from his current symptoms but comes in again in 4 months with a similar problem. What should be done for him at this visit? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
275 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Rosa is a 74‐year‐old woman who presents with a complaint of itching and soreness in her left side and upper back. She tells you that she has been gardening and that she thinks she may have a spider or bug bite, but she cannot see this area. She felt an “irritation” 2-3 days ago with inter-mittent itching. She took some oral OTC Benadryl © without benefit. She now complains of inter-mittent “shooting pain” and “tingling” sensations around the area of the left shoulder blade. She has been wearing a camisole instead of a bra for comfort. She denies itching in any other location on the body and has no other dermatological complaints. She denies recent trauma to the chest or back. She denies use of new shampoos, lotions, laundry products, clothing, perfumes, or topical agents. Past medical history: Positive for hypertension (HTN); osteoarthritis (OA, primarily of the knees and fingers); gout; osteoporosis, and polymyalgia rheumatica (PMR). Medications: Zestoretic, 1 tablet by mouth once per day; alendronate, 70 mg, by mouth, once per week; allopurinol, by mouth, 200 mg po once per day; Prilosec, 20 mg by mouth once per day; and prednisone, 7. 5 mg by mouth, once per day. She has been taking these medicines for over 1 year (with varying prednisone dose adjustments). Allergies: She denies any environmental, contact, or medication allergies. OBJECTIVE Head: Abundant, slightly dry hair in normal distribution with no alopecia or breaking. Head is normocephalic and atraumatic. Lymph nodes: No palpable lymphadenopathy in head, neck, thorax, or axilla. Skin: Pale with multiple scattered, small, bright‐red, pinpoint papules over the chest and back, as well as several irregularly shaped, flat, light‐brown macules. She has no visible rash, discoloration, Case 10. 8 Itching and Soreness By Sheila L. Molony, Ph D, APRN, GNP‐BC, FGSA, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
276 The Older Adult or lesion in the affected area, and no obvious insect bite or entry wound. Her skin is very dry in all areas. Thorax: Exquisite tenderness on palpation in the left subscapular area, extending to the anterior axillary line, lateral to the left breast. Her remaining physical examination is within normal limits. CRITICAL THINKING What is the most likely differential diagnosis and why?__Bug bite__Contact dermatitis__Eczema__Herpes zoster__Infestation (lice or scabies)__Medication‐related adverse effects__Polymyalgia rheumatica (exacerbation)__Rib fracture__Seborrheic dermatitis__Systemic disease__Xerosis (dry skin) Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?__Erythrocyte sedimentation rate (ESR or “sed rate”)__Immunoglobin E titer__Immunoglobin G titer for varicella zoster__Metabolic (chemical) profile including LFTs, BUN/creatinine, electrolytes, and TSH__Polymerase chain reaction (PCR) testing__Skin biopsy__Skin scraping for microscopy What is the management plan?Are any referrals appropriate at this time?Which of the clinical findings are consistent with normal aging changes?What are the most common causes of pruritus (itching) in older adults? What are the risks and benefits of antihistamine therapy for pruritus, such as diphenhydramine (Benadryl ©)? If new lesions continue to appear after 1 week, what additional considerations should be addressed? Which specific vaccines' dates of administration should be included in immunization documen-tation for older adults? How can excess disability be prevented?How can comfort (physical, psychosocial, and spiritual) be enhanced, beginning immediately? How can suffering be reduced? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
277 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Sharon, a 68‐year‐old obese woman, presents with bilateral knee pain described as “aching pain around the knee. ” The pain is worse going down stairs, with activity, and at night. She denies any recent trauma other than kneeling activities. She denies hearing any popping sounds or experi-encing any locking or giving way of the knee. She denies being bitten by a tick, although she does occasionally work in her garden. She denies fever or chills or general malaise or confusion. She is the mother of 4 adult children and 3 young grandchildren and stays very busy babysitting and helping in the children's households. However, the knee pain has recently limited her activities. When she was a young woman, she was athletic and participated in sports; but since her children grew up, she has been in a sedentary office job and rarely exercises. She has felt well and has not seen a health care provider for 5 years. She still gets occasional hot flushes but has not had a period for 16 years. She experiences vaginal dryness and states that she does not participate in sexual activity, as she is a widow. Past medical/surgical history: Sharon had surgery for carpal tunnel syndrome bilaterally 20 years ago. She also has had several suspicious skin lesions removed that have been benign. She had one episode of nephrolithiasis at age 35. Two of her children were born by cesarean section, and two were born via vaginal childbirth. There were no complications with any of the births. Family medical history: Her mother had rheumatoid arthritis and died of complications at age 55. Social history: Sharon is a nonsmoker, drinks “socially” (1 glass of red wine when she goes to a restaurant once each week), and has never used recreational drugs. Sharon lives alone but has her family and many friends to keep her busy. She feels safe at home and is generally happy with her life but a little tired from all of the babysitting and housework she has been doing. Medications: Her medications include a multivitamin and occasional aspirin or acetaminophen for “aches and pains. ” These medicines have relieved her knee pain somewhat but not to her satisfaction. Sharon is not aller gic to any medications. Case 10. 9 Knee Pain By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
278 The Older Adult OBJECTIVE Vital signs: Sharon is afebrile. Her blood pressure is 160/90; HR is regular and 84; respiratory rate is regular at 14. Her weight is 210 lbs. Cardiac: Regular rate and rhythm with no murmurs, clicks, gallops, or rubs. Respiratory: Lungs are clear bilaterally. Abdomen: Obese and soft without organomegaly or bruits. Musculoskeletal: Sharon's knees are mildly swollen without erythema or warmth. There is no tenderness to palpation. Drawer, Mc Murray, and Lachman tests are negative. The bulge and bal-lottement signs are also negative. There is mild nonpitting ankle edema. Skin: Without any current suspicious lesions or any rashes or ulcers. CRITICAL THINKING What is the most likely differential diagnosis and why? __Ligament strain or tear__Bursitis__Osteoporosis__Osteoarthritis__Patellofemoral syndrome__Gout__Pseudogout__Lyme disease__Rheumatoid arthritis Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?__Lyme titer__CBC__CMP__Lipids__TSH__Colonoscopy__Mammogram__Pelvic exam__ESR__Rheumatoid factor__CCP__DEXA scan__Vitamin D level What should be the plan of treatment?What should be the plan for health maintenance testing for this patient?Does this patient need gynecological care and treatment at this time?What is the plan for referrals and follow‐up? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
279 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. This case takes place in early August in the northeast United States. The heat index has exceeded 90o F for 4 days. Judith is an 84‐year‐old white woman who lives in low‐income senior housing in a heavily populated urban area. Her neighbor, who checks on Judith daily, finds Judith in apparent distress. The urgent care clinic is across the street so the neighbor gets one of the other neighbors to help get Judith to the clinic. The nurse practitioner examines Judith and finds her to be febrile with acute neurological changes (lethargic, confused, incoherent, and unable to follow commands), hypotensive, and tachycardic. The neighbor says that the apartment was very hot. Vital signs: Temperature: 103. 3 o F PO; HR: 110 ST; BP: 84/50; RR: 30; oxygen saturation 90% on room air. An intravenous line is placed, and a 500 m L bolus of normal saline is given to Judith at the clinic. Past medical history: HTN, hypercholesterolemia, and mild congestive heart failure (diagnosed 8 years ago); ejection fraction (40%). Social history: Judith lives alone in low‐income urban senior housing. She is a retired U. S. postal worker. Her apartment lacks air conditioning, but she does have a fan. She receives Meals on Wheels 3 times a week. Her husband of 45 years died 6 years ago. She has 3 children who visit approximately every 2 to 3 weeks. Other than family, she has limited social interaction outside the housing complex apart from an occasional visit with neighbors. Family history: Mother had hypertension and history of a myocardial infarction. Father had diabetes and died from complications of stroke. Adult children with unknown health backgrounds. Medications: Furosemide 20 mg PO daily; lisinopril 10 mg PO daily; metoprolol SR 50 mg PO daily; simvastatin 20 mg PO daily. Allergies: No known allergies. OBJECTIVE Vital signs: Temp: 102. 5o F core; HR: 106 ST; BP: 90/58; RR: 28; oxygen saturation: 96% on 2L nasal cannula. Case 10. 10 Hyperther mia and Mental Status Changes in the Elderly By Suellen Breakey, Ph D, RN, and Patrice K. Nicholas, DNSc, DHL (Hon), MPH, MS, RN, NP‐C, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
280 The Older Adult General: Judith is an 84‐year‐old white woman; height 5 ft 1 inch; weight 115 lb; no obvious signs of injury or distress noted; lying on stretcher. She is awake, unable to follow commands consis-tently, and appears restless (e. g., picking at sheets and oxygen tubing). HEENT: Lips are pale and dry; buccal mucosa and tongue are dry; no nodes or masses palpated. Neurological: Oriented to person only; speech slurred; pupils are 3 mm equal and reactive to light and accommodation; no obvious focal deficits noted; difficult to assess systematically due to patient's mental status. Cardiac: Normal S1, S2; no murmurs or bruits noted. Radial and distal pulses are 1+, equal bilat-erally; +CSM; no peripheral edema noted. Respiratory: Lungs are clear bilaterally; patient tachypneic but does not appear in distress; no nasal flaring or use of accessory muscles noted. Abdominal/GI: Abdomen soft, nontender; bowel sounds present in all 4 quadrants; no pain; no masses; no bruits noted. Musculoskeletal: Gait not assessed due to neurological changes. Evidence of crepitus bilaterally in knees on palpation. Hip flexion < 90 degrees. Skin/Dermatologic: Skin is hot, dry, and intact. CRITICAL THINKING What are the top three differential diagnoses in this case and why?Which diagnostic tests are required in this case and why?What are the concerns at this point?The elderly are particularly vulnerable to heat‐related illnesses (HRIs), such as heat exhaustion and heatstroke. List the symptoms and treatment associated with each condition. Identify six risk factors that Judith has for developing heatstroke and explain how each con-tributes to its development. Identify and explain three physical assessment findings from the case that support a diagnosis of heatstroke. Identify and explain three elements from the patient's history that support a diagnosis of heatstroke. What is the differential diagnosis for heatstroke?What is the plan of treatment?What are the plans for referral and follow‐up care?What health education should be provided to this patient?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat her?How does this patient's living in an urban area impact her risk for heatstroke?Are there any standardized guidelines that should be used to treat this case? If so, what are they? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 11 Resolutions Case 1. 1 Cardiovascular Screening Exam 283 Case 1. 2 Pulmonary Screening Exam 285 Case 1. 3 Skin Screening Exam 287 Case 1. 4 Oxygenation 289 Case 1. 5 Nutrition and Weight 291 Case 2. 1 Nutrition and Weight 293 Case 2. 2 Breastfeeding 295 Case 2. 3 Growth and Development 297 Case 2. 4 Heart Murmur 301 Case 2. 5 Cough 303 Case 2. 6 Diarrhea 305 Case 2. 7 Fall from Height 307 Case 3. 1 Earache 309 Case 3. 2 Bedwetting 311 Case 3. 3 Burn 315 Case 3. 4 Toothache 319 Case 3. 5 Abdominal Pain 321 Case 3. 6 Lesion on Penis 325 Case 4. 1 Rash without Fever 327 Case 4. 2 Rash with Fever 331 Case 4. 3 Red Eye 333 Case 4. 4 Sore Throat 337 Case 4. 5 Disruptive Behavior 339 Case 4. 6 Cough and Difficulty Breathing 341 Case 4. 7 Left Arm Pain 345 Case 4. 8 Nightmares 347 Case 4. 9 Gastrointestinal Complaint 351 Case 4. 10 Food Allergies 357 Case 4. 11 Obesity 363 Case 5. 1 Drug Use 365 Case 5. 2 Weight Loss 371 Case 5. 3 Menstrual Cramps 377 Case 5. 4 Missed Periods 383 Case 5. 5 Birth Contr ol Decision‐Making 387 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
282 Resolutions Case 5. 6 Vaginal Dischar ge 395 Case 5. 7 Sexual Identity 397 Case 5. 8 Knee Pain 399 Case 6. 1 Preconception Planning 403 Case 6. 2 Bleeding in the First Trimester of Pregnancy 405 Case 6. 3 Night Sweats 407 Case 6. 4 Pelvic Pain 417 Case 6. 5 Vaginal Itching 419 Case 6. 6 Redness and Swelling in the Breast 423 Case 6. 7 Sexual Assault 427 Case 6. 8 Abdominal Pain 431 Case 6. 9 Urinary Frequency 433 Case 6. 10 Headaches 435 Case 6. 11 Fatigue and Joint Pain 439 Case 6. 12 Muscle Tenderness 443 Case 6. 13 Insomnia 445 Case 7. 1 Fatigue 449 Case 7. 2 Testicular Pain 453 Case 7. 3 Prostate Changes 455 Case 8. 1 Substance Use Disorder (SUD) 459 Case 8. 2 Foot Ulcer 467 Case 8. 3 Abdominal Pain and Weight Gain 471 Case 8. 4 Burning Leg Pain 475 Case 8. 5 Difficulty Breathing 479 Case 8. 6 Epigastric Pain 481 Case 8. 7 Chest Pain and Dyspnea without Radiation 485 Case 8. 8 Chest Pain with Radiation 487 Case 8. 9 Persistent Cough and Joint Tenderness 491 Case 8. 10 Morning Headache 493 Case 8. 11 Facial Pain 495 Case 8. 12 Fatigue, Confusion, and Weight Loss 499 Case 8. 13 Hand Numbness 503 Case 8. 14 Chronic Diarrhea 507 Case 8. 15 Intractable Pain 511 Case 8. 16 Wrist Pain and Swelling 513 Case 9. 1 Sad Mood 515 Case 9. 2 More Than Depression 519 Case 9. 3 Postpartum Depression 525 Case 9. 4 Anxiety 529 Case 9. 5 Trauma 533 Case 10. 1 Forgetfulness 539 Case 10. 2 Behavior Change 543 Case 10. 3 Tremors 551 Case 10. 4 Weight Gain and Fatigue 555 Case 10. 5 Visual Changes 559 Case 10. 6 Back Pain 565 Case 10. 7 Acute Joint Pain 573 Case 10. 8 Itching and Soreness 577 Case 10. 9 Knee Pain 583 Case 10. 10 Hyperthermia and Mental Status Changes in the Elderly 587 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
283 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 1. 1 Cardiovascular Screening Exam RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? An electrocardiogram, chest X‐ray, and echocardiogram should all be performed. Results of diagnostic tests: ECG results are normal. CXR is normal. Echocardiogram reveals a patent ductus arteriosus. What is the most likely differential diagnosis and why? Patent ductus arteriosus (PDA): PDA is the most common congenital heart defect seen in premature infants. Intravenous indometh-acin (the drug of choice) often stimulates closure of the ductus arteriosus in premature infants. Nonsteroidal anti‐inflammatory drugs (NSAIDs) such as ibuprofen may also be used to stimulate closure of the PDA. Prophylaxis for infective endocarditis is required until the PDA is closed. No long‐term sequelae usually occur if the PDA is treated before pulmonary vascular disease develops. What is the plan of treatment, and what should be the plan for follow‐up care? Monitor weight and other growth parameters at subsequent visits. Provide emotional support. Allow the parents to verbalize their concerns about their baby's health maintenance. Facilitate mother‐infant attachment. Return to clinic in 4 days for 2‐week, well‐child check and weight check. Discuss signs and symptoms of increased work of br eathing (increased respiratory rate; inter-costal retractions; nasal flaring) with parents and when to call the office (decreased by‐mouth intake; decreased urine output; increased work of breathing; increased temperature ≥100. 4°F). Are there any referrals needed? Refer to cardiology for consideration of medication or sur gery to aid in the closure of the duct. Consider referral for genetic counseling r egarding future conception. Does the patient's psychosocial history influence how you might treat her? Since this mother is a single mother with two other children in the home, it is important for the health care provider to ensure that the family is referred to the appropriate social service agencies. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
284 Resolutions The family should be referred to the Women, Infants, and Children (WIC) program for supplemental food and infant formula services. Mothers with a lower socioeconomic status have been found to be more at risk for postpartum depression, so it will be important for the health care provider to screen this mother for postpartum depression at subsequent visits throughout the baby's first year of life. What if this baby were a girl? Girls have been noted to be affected by patent ductus arteriosus twice as often as boys. What if this baby had been born full term? Functional closure of the ductus occurs within 15 hours of birth in a normal full‐term infant, but true closure with the inability to reopen takes about 3 weeks. What if this baby had been born at a higher altitude? Babies born at higher altitudes are at increased risk for a patent ductus arteriosus. Are there any standardized guidelines that should be used to assess or treat this case? There are no standardized guidelines located in the literature for the assessment and/or treatment of patent ductus arteriosus. REFERENCES AND RESOURCES Conrad, C., Newberry, D., Harris‐Haman, P., & Zukowsky, K. (2019). Understanding the pathophysiology, implications, and treatment options of patent ductus arteriosus in the neonatal population. Advances in Neonatal Care, 19, 179-187. Havranek, T., Rahimi, M., Hall, H., & Armbrecht, E. (2015). Feeding preterm neonates with patent ductus arteriosus (PDA): Intestinal blood flow characteristics and clinical outcomes. Journal of Maternal‐Fetal & Neonatal Medicine, 28, 526-530. Hundscheid, T., van den Broek, M., van der Lee, R., & de Boode, W. (2019). Understanding the pathobiology in patent ductus arteriosus in prematurity—beyond prostaglandins and oxygen. Pediatric Research, 86, 28-38. Lewis, T., Shelton, E., Van Driest, S., Kannankeril, P., & Reese, J. (2018). Genetics of the patent ductus arteriosus (PDA) and pharmacogenetics of PDA treatment. Seminars in Fetal & Neonatal Medicine, 23, 232-238. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
285 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 1. 2 Pulmonary Screening Exam RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? It is important to obtain an arterial blood gas (ABG) to determine the level of gas exchange and acid‐base balance. The ABG results reveal mild respiratory and metabolic acidosis. Chest radiography is the diagnostic standard for transient tachypnea of the newborn. The chest radiograph shows generalized overexpansion of the lung (hypoaeration of alveoli) and flattened contours of the diaphragm, which are consistent with transient tachypnea of the newborn. What is the most likely differential diagnosis and why? Transient tachypnea of the newborn (TTN): Transient tachypnea of the newborn (TTN) is a self‐limited disease. Approximately 1% of neonates have some form of respiratory distress that is not associated with infection, such as transient tachy-pnea of the newborn. TTN results from a delay in clearance of fetal liquid from the lungs. Infants with TTN usually present with tachypnea within the first few hours of life. It has been associated with precipitous deliveries and births by cesarean section. It is also more common in babies born to mothers with diabetes. Medical care of TTN is supportive. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status of the infant typically improves. TTN resolves over a 24‐hour to 72‐hour period. What is the plan of treatment, referral, and follow‐up care? Begin oxygen therapy in the office. Refer the patient and family to the local emergency department for support of the respiratory system, a workup for possible sepsis (complete blood count, blood cultures, lumbar puncture for culture of cerebrospinal fluid, and urine culture), and consultation with a neonatologist. An ambulance should be called to transport the baby from the office to the emergency department so that the baby's airway and respiratory status may be maintained. Provide emotional support to the parents. Allow the parents to verbalize their concerns about their baby's health status. Facilitate mother‐infant attachment. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
286 Resolutions Are there any demographic characteristics that would affect this case? The risk for TTN is equal in males and females. There has been no association with race or ethnicity reported. TTN presents as respiratory distress in full‐term or near‐term infants. What if the patient lived in a rural, isolated setting? Health care providers practicing in rural, isolated settings should have emergency office plans in place for patients experiencing respiratory distress. Are there any standardized guidelines that should be used to assess or treat this case? There were no standardized guidelines located in the literature for the assessment and/or treatment of transient tachypnea of the newborn. REFERENCES AND RESOURCES Kayıran, S., Erçin, S., Kayıran, P., Gursoy, T., & Gurakan, B. (2019). Relationship between thyroid hormone levels and transient tachypnea of the newborn in late‐preterm, early‐term, and term infants. Journal of Maternal‐Fetal & Neonatal Medicine, 32, 1342-1346. Li, J., Wu, J., Du, L., Hu, Y., Yang, X., Mu, D., & Xia, B. (2015). Different antibiotic strategies in transient tachypnea of the newborn: An ambispective cohort study. European Journal of Pediatrics, 174, 1217-1223. Omran, A., Mousa, H., Abdalla, M., & Zekry, O. (2018). Maternal and neonatal vitamin D deficiency and transient tachypnea of the newborn in full term neonates. Journal of Perinatal Medicine, 46, 1057-1060. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
287 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 1. 3 Skin Screening Exam RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? Eosinophils will be noted on microscopic examination using a Wright stain. Eosinophilia may also be noted on peripheral blood studies. However, the diagnosis of erythema toxicum is usually made on the basis of clinical findings from the history and physical examination. No diagnostic testing is usually needed. What is the most likely differential diagnosis and why? Erythema toxicum: Erythema toxicum, also called erythema toxicum neonatorum or toxic erythema of the newborn, is a common skin condition seen in newborns. It is self‐limited and only occurs in the neonatal period. Herpes usually has more of a clustered and vesicular appearance, whereas the lesions of erythema toxicum are scattered. Milia are whitish, pearly bumps in the skin of newborns. The lesions are not on erythematous bases. Milia lesions typically occur on the cheeks, nose, and chin—and not on the trunk. The etiology of erythema toxicum is unknown. It may appear in up to 70% of newborns between 3 days and 2 weeks of life. Although the condition is harmless, it can be of great concern to the new parent. What is the plan of treatment? Erythema toxicum is not contagious and does not require any medical treatment. It usually resolves within 2 weeks after birth. Follow‐up care is not needed unless the condition persists or does not resolve by 2 weeks of life. Are any referrals needed? Erythema toxicum neonatorum is often diagnosed easily by pediatricians and family physicians. If the features are atypical, if the newborn appears ill, or if the newborn has risk factors for sepsis, consultation with a pediatric dermatologist may be advisable. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
288 Resolutions Does the patient's psychosocial history impact how you might treat her? The family has a pet dog. The lesions from erythema toxicum may sometimes resemble flea bites. Flea bites also should be considered among the differential diagnoses. Are there any demographic characteristics that would affect this case? There have been significant differences noted in the incidence of erythema toxicum based on race or gender. This condition is limited to the neonatal period. If an infant older than 28 days of age has a similar rash, then other diagnoses should be strongly considered. Are there any standardized guidelines that should be used to assess or treat this case? There are currently no standardized guidelines for the assessment and/or treatment of erythema toxicum. REFERENCES AND RESOURCES Chadha, A., & Jahnke, M. (2019). Common neonatal rashes. Pediatric Annals, 48, e16-e22. Shepard‐Hayes, A. (2019). Pediatric erythema toxicum. Retrieved from: https://emedicine. medscape. com/ article/909671‐overview Weatherspoon, D. (2018). Baby's skin. International Journal of Childbirth Education, 33, 13-17. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
289 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 1. 4 Oxygenation RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? A nasopharyngeal swab should be performed. A complete blood count (CBC) is seldom useful since the white blood cell (WBC) count is usually within normal limits. Chest radiographs are not routinely necessary. The nonspecific findings of hyperinflation and patchy infiltrates may be seen on the chest radiograph. Results of diagnostic tests: The nasopharyngeal swab was positive for RSV. What is the most likely differential diagnosis and why? Bronchiolitis: The most likely differential diagnosis is bronchiolitis related to an infection with RSV. Matthew's history and physical examination form the primary basis for the diagnosis of bronchiolitis. Bronchiolitis is usually due to a viral infection of the small lower airways (bronchioles). Infection is spread by direct contact with respiratory secretions. Previous infection does not confer immunity. Reinfection can be common. Early symptoms are those of a viral URI, including mild rhinorrhea, cough, and sometimes low‐grade fever. It is unlikely to be chlamydial pneumonia since the mother was successfully treated during the pregnancy. Scattered crackles with good breath sounds are characteristic of chlamydial pneumonia, and wheezing is usually absent. Conjunctivitis and mid-dle‐ear abnormality may be present in half the infants with chlamydial pneumonia. Chest radio-graphs will show bilateral interstitial infiltrates with hyperinflation. What is the plan of treatment, referral, and follow‐up care? Consider oxygen therapy in the office, and monitor Matthew's cardiac and r espiratory status. The American Academy of Pediatrics states that clinicians may choose not to administer sup-plemental oxygen if the child's oxygen saturation is above 90% on room air. Place Matthew in an upright position to facilitate respirations. The American Academy of Pediatrics recommends against the use of albuterol in infants and children with bronchiolitis. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
290 Resolutions Refer patient and family to the local emergency department for support of the r espiratory system, a workup for possible sepsis (complete blood count, blood cultures, lumbar puncture for culture of cerebrospinal fluid, and urine culture), and consultation with a neonatologist. An ambulance should be called to transport the baby from the office to the emergency department so that the baby's airway and respiratory status may be maintained. Provide emotional support to the parents. Allow the parents to verbalize their concerns about their baby's health status. Facilitate mother‐infant attachment. What demographic characteristics might affect this case? Race and socioeconomic status may affect the frequency of contracting bronchiolitis. Lower socio-economic status may increase the likelihood of hospitalization. Bronchiolitis occurs as much as 1. 25 times more frequently in males than in females. In cases of bronchiolitis, 75% of the cases occur in children younger than 1 year, and 95% occur in children younger than 2 years. Incidence peaks in those aged 2-8 months. Does the patient's psychosocial history impact how you might treat him? Matthew's father is a smoker; and the family has 2 cats. Both of these things may be lung irritants. What if the patient lived in a rural, isolated setting? Health care providers practicing in rural, isolated settings should have emergency office plans in place for patients experiencing respiratory distress. REFERENCES AND RESOURCES Condella, A., Mansbach, J., Kohei, H., Dayan, P., Sullivan, A. Espinola, J., & Camargo, C. (2018). Multicenter study of albuterol use among infants hospitalized with bronchiolitis. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 19, 475-483. Karampatsas, K., Kong, J., & Cohen, J. (2019). Bronchiolitis: An update on management and prophylaxis. British Journal of Hospital Medicine, 80, 278-284. Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A. M., Hernandez‐ Cancio, S. (2014). Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134, e1474-e1502. Rivera‐Sepulveda, A., Rebmann, T., Gerard, J., & Charney, R. (2019). Physician compliance with bronchiolitis guidelines in pediatric emergency departments. Clinical Pediatrics, 58, 1008-1018. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
291 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 1. 5 Nutrition and Weight RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? No tests are needed based on the history and physical examination. What is the most likely differential diagnosis and why? Overfeeding: Based on the history of the baby taking 5 oz of formula every 2 hours, the significant weight gain in the first 2 weeks of life, and the unremarkable physical examination, the most likely differential diagnosis is overfeeding. Gastroesophageal reflux disease (GERD) is often associated with failure to thrive. Neonates with GERD may also present with respiratory symptoms. Neonates with gastroenteritis may pr esent with diarrhea and fever—which this baby does not have. What is the plan of treatment and follow‐up care? Via a Spanish‐speaking medical interpreter, provide education about feeding, proper mixing of formula, and signs of satiety in neonates. Discuss ways to comfort the baby that do not involve feeding. Refer the family to the Women, Infants, and Children (WIC) Program for a consultation with a nutritionist and assistance with obtaining formula. Does the patient's psychosocial history impact how you might treat this case? Having a teenage mother who has limited English proficiency is an aspect of the patient's psycho-social history that may affect her treatment. Working with the mother and her family will require extra time during visits to ensure that the patient education and anticipatory guidance are properly understood. What demographic characteristics might affect this case? There are no particular race or socioeconomic characteristics that would affect overfeeding. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
292 Resolutions Are there any standardized guidelines that should be used to assess or treat this case? There are no known guidelines that focus on overfeeding in the neonate. The American Academy of Pediatrics has guidelines about the introduction of solids. REFERENCES AND RESOURCES Barfield, E., & Parker, M. (2019). Management of pediatric gastroesophageal reflux disease. JAMA Pediatrics, 173, 485-486. Barnhart, D. (2016). Gastroesophageal reflux in children. Seminars in Pediatric Surgery, 25, 212-218. Rostas, S., & Mc Pherson, C. (2018). Acid suppression for gastroesophageal reflux disease in infants. Neonatal Network, 37, 33-41. Singendonk, M., Brink, A., Steutel, N., van Etten‐Jamaludin, F., van Wijk, M., Benninga, M., & Tabbers, M. (2017). Variations in definitions and outcome measures in gastroesophageal reflux disease: A systematic review. Pediatrics, 140, 1-15. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
293 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 1 Nutrition and Weight RESOLUTION Which laboratory tests should be ordered as part of a 12‐month, well‐child visit? According to the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care guidelines, there are several tests that are recommended for the 12‐month well‐child visit. A hemoglobin or hematocrit is recommended at the well‐child visit to screen for iron defi-ciency anemia. A blood lead test is also recommended to screen for an elevated blood lead level. A tuberculin test is recommended if the child has risk factors for contracting tuberculosis, such as travel to an endemic area, residing in a homeless shelter, or visiting someone in jail. Neil's father is incarcerated. If he visits in father in jail, he should receive a screening for tuberculosis. Other than “well child,” what additional diagnoses should be considered for Neil? Based on the information gathered during his history and on his physical examination, there are several additional diagnoses that may be considered. Related to Neil's nutrition, there are 2 poten-tial diagnoses: at risk for constipation and at risk for iron deficiency anemia. Neil is drinking nearly 40 oz of cow's milk daily. This amount of milk is excessive for his age (recommended amount is 20-24 oz daily). Excessive milk intake is associated with iron‐deficiency anemia, as well as consti-pation. Regarding his weight, Neil is currently in the age range to develop physiologic anorexia of the toddler. Because the rate of growth decreases during the second year of life (between 1 and 2 years of age), this diagnosis signifies that the child needs fewer calories and therefore may be more likely to eat less. Another consideration is that Neil is becoming full from his excessive milk intake and may be less likely to be hungry for solid foods. What is the plan of treatment, referral, and follow‐up care? The plan of treatment for this visit would be to discuss the excessive milk intake, discuss iron‐rich foods, and discuss the decreased caloric needs of the young toddler compared to the young infant. Kayla should be advised to feed Neil solid foods before offering him milk. She should also be advised to wean Neil off the bottle and to feed him liquids from a cup only, limiting juice to 4 oz and cow's milk to 24 oz per day. A daily pediatric multivitamin may also be prescribed for Neil. Since Kayla already receives TANF and WIC services, she can be referred to the SNAP food stamp assistance program for additional help in acquiring nutritious foods for Neil. If further nutritional concerns arise, the family can be referred to a nutritionist. Neil should return to the | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
294 Resolutions office for a well‐child visit in 3 months for his 15‐month checkup. He should return sooner if there are signs and symptoms of illness. Does this patient's psychosocial history affect how you might treat this case? Neil's family is likely to be of a lower socioeconomic status (SES) based on their eligibility for gov-ernmental subsidies such as WIC, TANF, and Section 8. Because of their SES, the family may be less likely to be able to afford nutritious foods. This could affect Neil's weight and growth patterns. What if the patient lived in a rural setting? Living in a rural setting might further limit access to nutritious foods since there may be fewer local facilities where nutritious foods can be readily purchased. Are there any demographic characteristics that might affect this case? The family's low income status is the demographic factor in this case. Other demographic charac-teristics such as gender and ethnicity are not likely to affect this case. Are there any standardized guidelines that should be used to assess or treat this case? Refer to the Office of Disease Prevention & Health Promotion and American Heart Association resources in the References and Resources below for guidelines on nutrition and weight that might be used to assess or treat this case. REFERENCES AND RESOURCES American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup. (2019). 2019 recommendations for preventive pediatric health care. Pediatrics, 143. American Heart Association. (2019). Dietary recommendations for healthy children. https://www. heart. org/en/ healthy‐living/healthy‐eating/eat‐smart/nutrition‐basics/dietary‐recommendations‐for‐healthy‐children Lagemaat, M., Amesz, E., Schaafsma, A., & Lafeber, H. (2014). Iron deficiency and anemia in iron‐fortified formula and human milk‐fed preterm infants until 6 months post‐term. European Journal of Nutrition, 53, 1263-1271. Office of Disease Prevention and Health Promotion. (2015). Dietary guidelines for Americans 2015-2020 (8th ed. ). https://health. gov/dietaryguidelines/2015/guidelines/ Sopo, S., Arena, R., & Scala, G. (2014). Functional constipation and cow's milk allergy. Journal of Pediatric Gastroenterology & Nutrition, 59, e34-e34. U. S. Department of Agriculture Food and Nutrition Services. (2019). Special supplemental nutrition program for women, infants, and children (WIC). https://www. fns. usda. gov/wic U. S. Department of Agriculture Food and Nutrition Services. (2019). Supplemental nutrition assistance program (SNAP). https://www. fns. usda. gov/snap/supplemental‐nutrition‐assistance‐program | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
295 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 2 Breastfeeding RESOLUTION Which laboratory or diagnostic imaging tests should be ordered as part of a 9‐month, well‐child visit? According to the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care guidelines, there are no recommended laboratory tests or diagnostic imaging tests for the 9‐month, well‐child visit. However, based on Julio's history of receiving a low‐iron formula, the health care provider may consider obtaining a hemoglobin test to screen for iron‐deficiency anemia. If the hemoglobin is abnormally low, then the health care provider can obtain a full complete blood count to confirm the diagnosis of iron deficiency anemia. The AAP guidelines recommend that children at risk for lead poisoning (those children living at or below the poverty line who live in older housing) receive a risk‐assessment screening for lead poisoning at 9 months of age. What is the most likely differential diagnosis and why? Iron deficiency anemia and constipation: Based on the history provided by Julio's mother, diagnoses to consider would be iron deficiency anemia and constipation. What is the plan of treatment, referral, and follow‐up care? The plan of treatment would be to discuss nutrition, anticipatory guidance, and safety. For the 9‐month visit, the health care provider should discuss safety issues such as car safety (having the child in a rear‐facing car seat) and water safety (water temperature < 120 degrees; never leaving the baby in the bathtub alone; keeping the toilet lid and the bathroom door closed; emptying mop buckets after each use). In addition, the health care provider should discuss firearm safety, the pre-vention of burns, and the need for working smoke and carbon monoxide detectors. The health care provider should discuss anticipatory guidance topics such as introducing the cup and beginning to wean Julio off the bottle; reading to him each night; and discouraging televi-sion watching and encouraging more interactive activities that promote proper brain development, such as talking, playing, singing, and reading together. Nutrition topics such as the need for iron‐fortified formula, not low‐iron formula, to prevent iron deficiency anemia should be discussed. Nutritional suggestions should be given to prevent consti-pation associated with iron intake, such as pureed prunes or prune juice. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
296 Resolutions The family may be referred to the WIC (Women, Infants, and Children) program for assistance with obtaining formula and iron‐fortified infant cereals. The WIC program has nutritionists on staff who will be able to provide Julio's family with nutritional education. Julio should follow up for a well‐child visit at 1 year of age or sooner as needed for signs and symptoms of illness. Does this patient's psychosocial history affect how you might treat this case? The language difference between the health care provider and the patient's family may be a poten-tial barrier to receiving effective health care—even with the use of a certified medical interpreter. Because of this barrier, the health care provider may need to spend extra time when working with this family. What if the patient lived in a rural setting? It may be difficult to obtain appropriate medical interpreter services for families living in rural set-tings. This may prompt health care providers to use family members for interpretation, which could compromise patient confidentiality. Telephone interpreter services are available for use for practices without in‐person interpreters. Also, obtaining supplemental nutrition services such as WIC may be difficult because of lack of access to nearby WIC distribution centers. Are there any demographic characteristics that might affect this case? Besides being of Hispanic ethnicity and not speaking English, age is a demographic factor that might affect this case. At 9 months of age, Julio likely has no maternal iron stores; and since he is consuming low‐iron formula and not taking multivitamins, he is at risk for iron deficiency anemia. Are there any standardized guidelines that should be used to assess or treat this case? The American Academy of Pediatrics has issued several clinical practice guidelines that may assist health care providers during well‐child visits. For more information, refer to the resources below and their web links. REFERENCES AND RESOURCES American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Bright Futures Periodicity Schedule Workgroup. (2019). 2019 recommendations for preventive pediatric health care. Pediatrics, 143. American Heart Association. (2019). Dietary recommendations for healthy children. https://www. heart. org/en/ healthy‐living/healthy‐eating/eat‐smart/nutrition‐basics/dietary‐recommendations‐for‐healthy‐children Centers for Disease Control and Prevention. (2009). Lead prevention tips. http://www. cdc. gov/nceh/lead/ tips. htm Martin‐Marcotte, N. (2018). Functional constipation in children: Which treatment is effective and safe? An evidence‐based case report. Journal of Clinical Chiropractic Pediatrics, 17, 1485-1489. Powers, J., & Buchanan, G. (2014). Iron deficiency in toddlers to teens: How to manage when prevention fails. Contemporary Pediatrics, 31, 12-17. U. S. Department of Agriculture Food and Nutrition Services. (2019). Special supplemental nutrition program for women, infants, and children (WIC). https://www. fns. usda. gov/wic | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
297 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Many cases of children not gaining weight are nonorganic, so a history and physical examination are normally all that are needed. Certain laboratory tests may help to screen for an underlying pathologic condition. A complete blood count (CBC) can be ordered as well as a urinalysis and urine culture. If an electrolyte imbalance is suspected, electrolytes including blood urea nitrogen (BUN) and creatinine can be ordered. Liver function tests may also be ordered to rule out an under-lying liver condition. If it is suspected that the infant is having a physical problem such as difficulty swallowing, a modified barium swallow may be ordered. This test would be done under the directions of a feeding therapist and a radiologist. During the test, the infant would be given liquids and solids differing in consistency. The infant's swallows would be filmed to determine if there are swallow-ing difficulties that are contributing to the lack of weight gain. A chest radiograph would be helpful in assessing whether a cardiopulmonary disease is a contributing factor. What is the most likely differential diagnosis and why? Nonorganic failure to thrive: With an infant who is not gaining weight, there are several differential diagnoses to consider, including organic failure to thrive, nonorganic failure to thrive (FTT), constitutional growth delay, and fetal alcohol spectrum disorder. We do not know much about Kilah's birth and past history—only that she was removed from her mother's care and placed in foster care. Because it is unknown whether or not she was exposed to substances, including alcohol, in utero, it would be wise to ini-tially consider a diagnosis of fetal alcohol spectrum disorder as a contributing factor to the failure to gain weight. Children with true fetal alcohol syndrome display a failure to gain weight, as well as distinct facial anomalies; and they typically have cognitive/developmental impairment. Those with fetal alcohol spectrum disorder may display growth and cognitive delays but may or may not have the distinct facial features that are associated with fetal alcohol syndrome. Given Kilah's history, there was nothing on the physical examination or in the history to indicate that she has distinct facial anomalies or any delays in development. Based on these findings, it is likely that both fetal alcohol spectrum disorder and fetal alcohol can be ruled out as causes for Kilah's growth impairment. Case 2. 3 Growth and Development | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
298 Resolutions Constitutional growth delay may also be considered in the differential diagnoses for a failure to gain weight. Children with constitutional growth delay may have linear growth velocity and weight gain that slows beginning as early as age 3-6 months. We do not have information on this child's linear growth velocity. We have only one length measurement, which would not tell us whether or not the linear growth velocity is stable, increasing, or decreasing. However, most chil-dren who have constitutional growth delay do not seek medical attention until puberty, when a lack of sexual development becomes apparent and a discrepancy in height from peers is noted because of the delay in pubertal growth spurt. This makes it likely that Kilah does not have consti-tutional growth delay and that her care provider should consider other diagnoses. Organic FTT usually results from problems such as neuromuscular abnormalities, craniofacial abnormalities, or lack of appetite. Other conditions that may result in organic FTT include breathing difficulties, significant developmental delay, and primary gastrointestinal disease or dysfunction. The information obtained in Kilah's history and on her physical examination does not indicate that she suffers from any of the aforementioned problems, making organic FTT an unlikely diagnosis. Nonorganic FTT usually results from adverse environmental and psychosocial factors. It may be associated with abnormal interactions between the caregiver and the infant. This may result in an inadequate provision of food and/or inadequate intake of food. Nonorganic FTT is most common in the setting of poverty. Its causes may include a combination of poverty and lack of preparation for parenting. An important part of the evaluation of all children is observation of the infant while feeding. Observing infants while they are feeding sheds light on maternal‐infant interactions. Given Kilah's history and physical examination and the elimination of the previous diagnoses, nonorganic FTT is the most likely diagnosis at this time. Kilah's caregiver has not cared for an infant in the past, so it may be possible that she is unaware of the caloric needs of a 9‐month‐old. A 9‐month‐old infant needs an approximate caloric intake of 140 kilocalories (kcal)/kilogram (kg) per day. Calculating Kilah's daily caloric needs (6. 4 kg × 140 kcal) means that she would need 896 kcal per day. Calculating her caloric intake based on her reported history, Kilah's daily caloric intake is less than her calculated caloric needs. Calories in regular infant formula are 20 kcal/oz. Kilah's stated intake is 24 oz of formula daily, which provides her with 480 kcal/day. She also eats 2 jars of stage 1 baby food daily. Stage 1 baby foods typically have 25-50 kcal/jar, providing Kilah with an additional 50-100 kcal per day. Kilah's approximate caloric intake per day is 530-580 kcal, far below her daily caloric need of 896 kcal. Also, Kilah's foster mother does not work outside the home and receives several government housing and food subsidies. Her eligibility for these subsidies makes it likely that she lives at or near the poverty line, a risk factor for nonorganic FTT. What is your plan of treatment, referral, and follow‐up care? The goal for Kilah would be to provide her with adequate caloric intake for growth. In this case, it would appear that Kilah can be treated for her nonorganic FTT on an outpatient basis. However, frequent follow‐up visits are necessary (initially at 2-4 weeks, then at least monthly thereafter). Kilah's weight gain, linear growth velocity, head circumference, and daily caloric intake should be recorded at each follow‐up visit. Her weight, length, and head circumference should be plotted on the same age‐appropriate growth chart over time. Angela should be instructed on proper caloric intake for Kilah and on ways to increase calories in Kilah's diet. Home visits from the health care provider or an outreach worker may assist in determining the underlying reason for the nonor-ganic FTT. If outpatient treatment does not lead to documented weight gain, hospitalization may be necessary for diagnostic and therapeutic reasons. When treating an infant with FTT, a multidisci-plinary team approach should be used. A pediatric health care provider, nutritionist, and social worker should be a part of the team. A mental health care professional may also be included. This team should complete a thorough evaluation of the family's psychosocial situation and determine if future support is required. A home visit can help to support the caregiver. The family may also be referred to a local food bank if food affordability is a problem. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Growth and Development 299 Does this patient's psychosocial history affect how you might treat this case? Kilah's psychosocial history does affect how this case would be treated. Kilah is in foster care. It is essential that her foster care worker be informed of a diagnosis. Through the state's child protective services, Kilah's foster care worker may be able to provide additional support (social and financial) for Angela. They may also need to determine if Kilah would be better cared for in a foster home where the foster mother is knowledgeable about infant nutrition and care. What if the patient lived in a rural setting? If this patient and her foster family lived in a rural setting, having frequent follow‐up appoint-ments in the office might not feasible. In that case, the health care provider could consider employ-ing the services of a visiting nurse service to visit the home monthly to monitor Kilah's weight and nutritional status. The family's ability to obtain additional food through a source such a food bank may be limited as there may not be one in the area. Are there any demographic characteristics that might affect this case? While failure to thrive can occur in any socioeconomic strata, nonorganic FTT is more likely to occur in families living in poverty. There is an increased incidence of nonorganic FTT in children receiving Medicaid, children living in rural areas, and those who are homeless. While the exact reason is unknown, nonorganic FTT is more likely to occur in females than in males. In regard to age in the pediatric population, the most likely age groups to have nonorganic FTT are infants and toddlers. Are there any standardized guidelines that you should use to assess or treat this case? Homan (2016) provides guidelines for the detection and treatment of failure to thrive. REFERENCES AND RESOURCES Homan, G. (2016). Failure to thrive: A practical guide. American Family Physician, 94, 295-300. Larson‐Nath, C., Mavis, A., Duesing, L., Van Hoorn, M., Walia, C., Karls, C., & Goday, P. (2018). Defining pedi-atric failure to thrive in the developed world: Validation of a semi‐objective diagnosis tool. Clinical Pediatrics, 58, 446-452. Sirotnak, A. (2018). Failure to thrive. Retrieved from: https://emedicine. medscape. com/article/915575‐overview Vachani, J. (2018). Failure to thrive: Early intervention mitigates long‐term deficits. Contemporary Pediatrics, 35, 14-27. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
301 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 4 Heart Mur mur RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Based on the history and physical examination, no imaging studies are needed. However, if any of the listed studies were ordered, no abnormalities would be noted on the test. What is the most likely differential diagnosis and why? Still's murmur: Still's murmur is a murmur that is classified as “functional,” “innocent,” or “physiologic. ” It is not a structural defect of the heart and may be a result of noise flowing through a normal heart. There is no known cause. Neither a PDA nor a VSD are position‐dependent (heard louder in the supine position). Also, the vibratory quality of the murmur is consistent with a Still's murmur. PDA is more common in infants born prematurely. What is your plan of treatment, referral, and follow‐up care? Discuss physiologic murmurs with the parents and explain that no limitation on activity is r equired. Monitor weight and other growth parameters at subsequent visits. Allow the parents to verbalize their concerns about their baby's health maintenance. Discuss signs and symptoms of increased work of br eathing (increased respiratory rate; inter-costal retractions; nasal flaring) with parents and when to call the office (decreased by mouth intake; decreased urine output; increased work of breathing; increased temperature). Return to clinic in 3 months for well‐child check or sooner as needed. Are there any referrals needed? Consider a referral to cardiology. However, a referral for a Still's murmur in a child 1 year old or greater is not required. Does the patient's psychosocial history impact how you might treat him? There are no known psychosocial factors that would affect the treatment of this patient. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
302 Resolutions What if this baby were a girl? There are no known gender differences in the occurrences of Still's murmur. What if this baby were 6 months old? Infants less than 1 year of age should be referred to a cardiologist for evaluation of all murmurs. Are there any standardized guidelines that should be used to assess or treat this case? There were no standardized guidelines located in the literature for the assessment and/or treatment of Still's murmur. REFERENCES AND RESOURCES Foppa, M., Rao, S., & Manning, W. (2015). Doppler echocardiography in the evaluation of a heart murmur. JAMA: Journal of the American Medical Association, 313, 1050-1051. Lefort, B., Cheyssac, E., Soulé, N., Poinsot, J., Vaillant, M., Nassimi, A., & Chantepie, A. (2017). Auscultation while standing: A basic and reliable method to rule out a pathologic heart murmur in children. Annals of Family Medicine, 15, 523-528. Mitchell, S., Dalal, N., Frank, L., Clauss, S., Aljohani, O., Bradley‐Hewitt, T., Harahsheh, A., & Dzelebdzic, S. (2018). Recurrent cardiology evaluation for innocent heart murmur: Echocardiogram utilization. Clinical Pediatrics, 57, 1436-1441. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
303 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 5 Cough RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Based on the history and physical findings, there are no laboratory or imaging studies needed other than a CXR. However, if a CBC were obtained, the results would show nonspecific findings such as an elevated white blood count. An ABG examination is not necessary since the child does not appear to be in respiratory distress. The CXR reveals a steeple sign; it signifies subglottic nar-rowing during inspiration. What is the most likely differential diagnosis and why? Croup: Croup is the most likely differential diagnosis based on the history, physical examination findings, and the chest X‐ray findings of steeple sign. The presence of inspiratory stridor, low‐grade fever, and barking cough support the diagnosis of croup. With epiglottitis, the child usually appears toxic, and the fever is usually 40°C or higher. With epiglottitis, marked restlessness and extreme anxiety may be present. Infants with bronchiolitis are more likely to have expiratory wheezing and rales, as opposed to inspiratory stridor. What is the plan of treatment, referral, and follow‐up care? Begin oxygen therapy in the office. The child should be kept as comfortable as possible. She should be allowed to remain in her parent's arms. Unnecessary painful interventions that may cause agi-tation and increased oxygen requirements by the child should be avoided. Monitor heart rate, respiratory rate/effort, and pulse oximetry. A single dose of dexamethasone should be administered in the office, and the child should be monitored for improvement. If no improvement is seen, refer the patient and family to the local emergency department for support of the respiratory system. An ambulance should be called to transport the baby from the office to the emergency department so that the baby's airway and respiratory status may be maintained. Antibiotics are not indicated. Provide emotional support to the parents. Allow the parents to verbalize their concerns about their baby's health status. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
304 Resolutions Are there any demographic characteristics that would affect this case? Male‐to‐female ratio for croup is approximately 1. 4:1. Croup occurs most frequently between the ages of 7 months and 36 months. While croup is rare after 6 years of age, it may present as late as 15 years. What if the patient lived in a rural, isolated setting? Health care providers practicing in rural, isolated setting should have emergency office plans in place for patients experiencing respiratory distress. REFERENCES AND RESOURCES April, M., & Long, B. (2019). Do glucocorticoids improve symptoms and reduce return visits or admission rates among children with croup? Annals of Emergency Medicine, 73, 459-461. Gates, A., Johnson, D., & Klassen, T. (2019). Glucocorticoids for croup children. JAMA Pediatrics, 173, 595-596. Newsom, C. (2019). Using glucocorticoids to treat croup in children. AJN: American Journal of Nursing, 119, 21-21. Parker, C., & Cooper, M. (2019). Prednisolone versus dexamethasone for croup: A randomized controlled trial. Pediatrics, 144, 1-9. Smith, D., Mc Dermott, A., & Sullivan, J. (2018). Croup: Diagnosis and management. American Family Physician, 97, 575-580. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
305 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 6 Diarrhea RESOLUTION Which laboratory or imaging studies should be considered to assist with or confirm the diagnosis? A CBC would not provide any clinically useful information in this case. The white blood count (WBC) may be elevated but that is a nonspecific finding as the WBC is likely to be elevated with most infectious processes. A stool culture may provide identification of an infectious organism that is causing the diarrhea. They are not done routinely for acute cases of pediatric diarrhea that are being treated in the outpatient setting. Electrolyte levels can be obtained if there is a concern of dehydration. A hydrogen breath test may be helpful in diagnosing older children with lactose intolerance, but this test is not usually done on babies and very young children because it can cause severe diarrhea. Similarly, a lactose tolerance test can aid in the diagnosis of lactose intolerance, but it is usually not performed on babies and very young children. What is the most likely differential diagnosis and why? Viral gastroenteritis: The complaint of diarrhea can lead to several differential diagnoses. The most common differen-tials for someone with David's history are viral gastroenteritis, antibiotic‐associated diarrhea, and lactose intolerance. Differentiating between these conditions requires a thorough history and review of systems. Viral gastroenteritis should be considered as David has had diarrhea, vomiting, and fever. He also recently started a new day care, which is a risk factor for viral gastroenteritis. David recently finished a course of antibiotics, which could be a possible source of diarrhea. Whole milk was introduced into the diet, which may lead the health care provider to consider lactose intolerance. Based on the history and physical exam, viral gastroenteritis due to rotavirus is the most likely of the differential diagnoses. The presence of fever likely rules out noninfectious causes of diarrhea. Rotavirus is one of several viruses known to cause gastroenteritis. It commonly affects children in the winter months in the United States but may occur year‐round in developing countries. Many children under the age of 5 years have come into contact with this virus at some point in their lives. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
306 Resolutions What is the plan of treatment, referral, and follow‐up care? In the majority of cases of viral gastroenteritis infection related to rotavirus, no medications are necessary. Antidiarrheal agents should typically be avoided in young children. Antibiotics are not indicated and may include diarrhea as a side effect—worsening the diarrhea. Hyperosmolar bev-erages such as sports drinks should be avoided because they may cause infants to develop hyper-natremia. Excessive plain water intake may cause infants to develop hyponatremia. Beverages such as Pedialyte® have the correct balance of glucose, sodium, and potassium and should be encouraged in small, frequent feedings for the child with viral gastroenteritis secondary to rota-virus. Because rotavirus is contagious, family members should be encouraged to practice good hand washing after changing diapers and before preparing meals. David's mother should be instructed that the diarrhea may last 1 full week. She should also be instructed about the signs and symptoms of dehydration and told to seek care immediately if any of these signs and symptoms develops. Based on the history and physical findings, no referrals are needed at this time. David's mother should be allowed to express her concerns regarding his illness status, espe-cially since he is just recovering from acute otitis media and also since she believed that she may have contributed to the diarrhea with the introduction of food with curry or the introduction of whole milk. Are there any demographic factors that should be considered? There have been no racial/ethnic factors that contribute to the development of rotavirus, but it has been shown that it is more prevalent among those of lower socioeconomic status. Are there any standardized guidelines that should be used to assess or treat this case? The Advisory Committee on Immunization Practices (ACIP) has developed guidelines for the pre-vention of rotavirus in infants and small children. REFERENCES AND RESOURCES Black, R. (2019). Progress in the use of ORS and zinc for the treatment of childhood diarrhea. Journal of Global Health, 9, 1-3. Duncan, D. (2018). Gastroenteritis: An overview of the symptoms, transmission, and management. British Journal of School Nursing, 13, 484-488. Freedman, M. (2019). Probiotics vs placebo against gastroenteritis. Contemporary Pediatrics, 36, 2. Hartman, S., Brown, E., Loomis, E., & Russell, H. (2019). Gastroenteritis in children. American Family Physician, 99, 159-165. Onyon, C., & Dawson, T. (2018). Gastroenteritis. Paediatrics & Child Health, 28, 527-532. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
307 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 2. 7 Fall from Height RESOLUTION Which laboratory tests should be ordered as part of a workup after a fall from height? Since Victor hit his head, any laboratory tests or imaging studies would be geared toward diag-nosing an intracranial bleed. There is no clear consensus regarding whether all patients with mild head injuries should have neuroimaging. If imaging is determined to be necessary, a CT scan is the diagnostic study of choice in the evaluation of a head injury because it has a rapid acquisition time, is nearly universally available, is easily interpretable, and is reliable. For those with obvious signs of a traumatic brain injury (TBI), such as evidence of skull fracture on physical exam, or neurologic changes, obtaining a head CT scan has a clear benefit. However, for patients without obvious signs of TBI, the decision to perform a head CT scan requires more consideration, since patients with minor head injuries may receive unnecessary CT scans that provide no clinical benefit. What is the most likely differential diagnosis and why? There are several diagnoses that should be considered for a child with a head injury, including minor closed head injury, subdural hematoma, subarachnoid hemorrhage, and epidural hema-toma. There are several factors from this case that lead to the diagnosis of minor head injury. Victor's Glasgow Coma Scale (GCS) was 15/15, there were no focal neurological deficits, and there was no seizure activity. These factors support a diagnosis of mild closed head injury. Additional factors that support this diagnosis are that there was no vomiting, no loss of consciousness, the fall was less than 1 meter, and there was no fluid or drainage from Victor's nose or ears. Patients with a subarachnoid hemorrhage typically have vomiting and loss of consciousness. There were no focal neurologic findings, and there was a GCS of 15/15. Patients with a subdural hematoma generally lose consciousness (although this is not an absolute) and typically experience moderate to severe blunt head trauma. Epidural hematoma may present with loss of consciousness, vomiting, and seizures. What is the plan of treatment, referral, and follow‐up care? Based on Victor's history, physical examination, and likely diagnosis of a mild closed head injury, he should be observed in the office and would likely not need radiographic evaluation or neuroim-aging. There will be no limitations on his activity or diet. His mother can be told to apply ice for | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
308 Resolutions 20 minutes at a time (every 2-4 hours as needed) to his head wound for 24 hours. This will help to reduce or prevent swelling of the injured area. Victor can be discharged to home if it is determined that he has a reliable caregiver at home who can monitor him for signs of complications related to his head injury. Victor's caregivers should be given an instruction sheet for head injury care that explains that he should be awakened every 2 hours and assessed neurologically. Victor's caregivers should be instructed to seek medical attention if he develops persistent nausea and vomiting, seizures, unusual behavior, or watery discharge from either the nose or the ears. There are no refer-rals necessary based on Victor's history and physical examination findings. Does this patient's psychosocial history affect how you might treat this case? An aspect of Victor's psychosocial history that might affect the handling of his case is that both of his parents are teenagers. Previous research has shown that children of adolescent mothers (when compared to children of adult mothers) have an increased rate of unintentional injuries during the first 5 years of life. What if the patient lived in a rural setting? A patient living in a rural setting may not be able to access a health care center in a timely fashion for assessment and diagnostic testing of a head injury after a fall. Are there any demographic characteristics that might affect this case? There are no specific demographics that affect this case. There are no known associations of unin-tentional head injury with ethnicity or gender in the pediatric population. REFERENCES AND RESOURCES Gelernter, R., Weiser, G., & Kozer, E. (2018). Computed tomography findings in young children with minor head injury presenting to the emergency department greater than 24h post injury. Injury, 49, 82-85. Harris, L., Axinte, L., Campbell, P., & Amin, N. (2019). Computer Tomography (CT) for head injury: Adherence to the National Institute for Health and Care Excellence (NICE) criteria. Brain Injury, 33, 1539-1544. Miescier, M., Dudley, N., Kadish, H., Mundorff, M., & Corneli, H. (2017). Variation in computed tomography use for evaluation of head injury in a pediatric emergency department. Pediatric Emergency Care, 33, 156-160. Osmond, M. H., Klassen, T. P., Wells, G. A., Davidson, J., Correll, R., Boutis, K., & Pediatric Emergency Research Canada (PERC) Head Injury Study Group. (2018). Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ: Canadian Medical Association Journal, 190, E816-E822. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
309 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 3. 1 Earache RESOLUTION Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for ear pain? Middle ear effusion may be confirmed with the observation of decreased or absent tympanic mem-brane mobility with pneumatic otoscopy. Unfortunately, when performing pneumatic otoscopy in infants and young children, it can be very difficult to maintain a tight‐fitting seal for the exam. Tympanometry may be performed to determine the presence of fluid (infected or uninfected) in the middle ear. Tympanometry is useful if cerumen makes visualization of the tympanic membrane difficult on otoscopic exam. Tympanocentesis, though not often done, may be performed to acquire a sample of the fluid behind the tympanic membrane for culture and sensitivity if the child is immunocompromised or has failed previous courses of antibiotic therapy. What is the most likely differential diagnosis and why? Otitis media:The complaint of ear pain can lead to several differential diagnoses. Acute otitis media, otitis externa, cholesteatoma, foreign body, and hemotympanum (blood behind the tympanic mem-brane) are some of the more common causes of ear pain in a child. A thorough history and careful physical exam will help to differentiate among these diagnoses. Otitis media is the most likely diagnosis for Janice based on the history and physical examina-tion findings. Janice had a fever, sleep and eating disturbances, and a previous history of otitis media. On examination, the left TM was erythematous and bulging. It is unlikely to be otitis externa as there is no ear pain elicited by palpation of the external ear, a characteristic sign of otitis externa. Cholesteatoma should be considered in the differential because of Janice's past diagnosis of otitis media. However, there was no pocket of retraction, keratinous debris, or mass on the tympanic membrane, ruling out a diagnosis of cholesteatoma. What is the plan of treatment, referral, and follow‐up care? The first‐line treatment for uncomplicated otitis media in a child with a temperature less than 39°C (102. 2°F) is amoxicillin, 80-90 mg/kg per day for 7-10 days. For children 6 years and older, a 5-7 day course of amoxicillin is appropriate. For children with a temperature over 39°C (102. 2°F) or if | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
310 Resolutions H. influenza or M. catarrhalis are suspected, therapy should start with amoxicillin‐clavulanate (90 mg/kg per day of amoxicillin and 6. 4 mg/kg per day of clavulanate) in 2 divided doses per day. In patients with non-Type 1 allergic reactions to amoxicillin, a cephalosporin may be used (cef-dinir 14 mg/kg per day in 1 or 2 doses, cefpodoxime 10 mg/kg per day once daily, or cefuroxime 30 mg/ kg per day in 2 divided doses). If the child has experienced a Type 1 reaction in the past (anaphylaxis or urticaria), azithromycin (10 mg/kg per day on the first day, then 5 mg/kg for 4 days) or clarithromycin (15 mg/kg per day in 2 divided doses) may be used. Because Janice has had hives in the past when using penicillin, azithromycin is the best choice for her. At 14 kg, her dose on day 1 would be 140 mg and on days 2 through 5, her dose would be 70 mg. Using the 100 mg/5 m L oral suspension, her dose would be 7 m L on day 1, then 3. 5 m L for days 2 through 5. Based on the history and physical exam findings, no referrals are needed at this time. Janice's mother, Marsha, should be instructed to follow up with a call to the office or to seek medical attention if no improvement is seen in 48-72 hours after the first dose of medication. Janice's fever should be lowered, and her sleeping and eating should also improve in 48-72 hours. Does this patient's psychosocial history affect how you might treat this case? Janice's psychosocial history contains elements that may increase her risk for developing otitis media. Her enrollment in a child care center places her at an increased risk for developing otitis media. Janice's father is a smoker. Exposure to passive cigarette smoke has been found to be a risk factor for the development of otitis media in preschool children. This information can be discussed with Janice's parents. Janice's father can be given information on smoking cessation resources. What if the patient lived in a rural setting? If Janice lived in a rural setting, her parents would be given clear instructions about when and how to follow up if there is no improvement in the 48‐ to 72‐hour window or if symptoms worsen. If an emergency department is not easily accessible, Janice should be followed closely by her primary care provider to ensure that worsening symptoms are not left unnoticed. Are there any demographic characteristics that might affect this case? Otitis media has been found to be more frequent in certain racial groups, such as the Inuit and American Indians. The difference in the frequency of occurrence compared to other racial groups is likely due to anatomic differences in the Eustachian tube. Regarding gender, boys have been found to be affected more commonly than girls. No specific causative factors for this have been found in the literature. Age is a demographic characteristic that affects otitis media. Otitis media occurs more commonly in infants, toddlers, and preschool children between the ages of 6 months and 3 years of age. This age distribution may be due to a combination of several factors. These factors can be immunologic, such as lack of pneumococcal antibodies, and/or anatomic. Younger children have a low angle of the Eustachian tube with relation to the nasopharynx. REFERENCES AND RESOURCES Chang, J., Shapiro, N., & Bhattacharyya, N. (2018). Do demographic disparities exist in the diagnosis and sur-gical management of otitis media? Laryngoscope, 128, 2898-2901. Gaddey, H., Wright, M., & Nelson, T. (2019). Otitis media: Rapid evidence review. American Family Physician, 100, 350-356. Homme, J. (2019). Acute otitis media and group A streptococcal pharyngitis: A review for the general pediatric practitioner. Pediatric Annals, 48, e343-e348. Marom, T., Kraus, O., Habashi, N., & Tamir, S. (2019). Emerging technologies for the diagnosis of otitis media. Otolaryngology-Head & Neck Surgery, 160, 447-456. Medhurst, R. (2018). Homeopathy for the management of otitis media. Journal of the Australian Traditional‐ Medicine Society, 24, 28-30. Van Wyck, F. (2018). Tympanocentesis. Retrieved from: https://emedicine. medscape. com/article/1413525‐overview | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
311 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What laboratory tests or diagnostic imaging studies should be ordered as part of a workup for bedwetting? A urine dipstick will provide information on hydration, infection, diabetes insipidus, or diabetes mellitus by measuring the urine specific gravity, nitrites, glucose, and ketones. A urine culture can be done if infection is suspected to identify the organism. In preschool‐aged children with enuresis and a urinary tract infection (UTI), consider a renal and bladder ultrasound. If abnormalities are found on the ultrasound, a voiding cystourethrography (VCUG) to identify structural abnormal-ities and measure bladder filling can be obtained. An X‐ray of the kidney, ureters, and bladder can be done if constipation or abnormalities of the spine are suspected. Urodynamic studies measure the flow of urine qualitatively and quantitatively and may be used if a neurological disorder is suspected or in children with daytime wetting who do not respond to traditional therapies. What is the most likely differential diagnosis and why? Enuresis: Bedwetting, or enuresis, has many etiologies. Enuresis refers to involuntary urinary incontinence beyond the expected age of 4 years for daytime dryness and 5 years for night dryness. It may involve genetic factors, changes in vasopressin secretion, sleep factors, structural abnormalities, infection, or psychological factors. Primary nocturnal enuresis (PNE) is defined as a child > 5 years who is incontinent at night with no previous history of dryness at night for an extended period of time. Secondary enuresis refers to episodes of bedwetting after a period of dryness > 6 months and can be precipitated by a stressful event in the child's life. The most common differentials for enuresis are urinary tract infection, diabetes mellitus, diabetes insipidus, structural abnormalities of the genitourinary tract, constipation, excessive caffeine, spinal cord injury, or psychological stress. A UTI may be the source when there is dysuria, urinary frequency, and a positive urine culture. High glucose or ketones in the urine dip would indicate diabetes mellitus, and a low specific gravity would indicate diabetes insipidus. Abdominal palpation of stool or stool visible on a KUB (kidneys, ur eters, and bladders) X‐ray would indicate constipation. Abnormal physical exams of the spine or reflexes can indicate an underlying neuro-logic disorder or spinal cord injury. Structural abnormalities are identified with a renal and bladder ultrasound, VCUG, or urodynamic studies. In the absence of clinical evidence for enuresis, a Case 3. 2 Bedwetting | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
312 Resolutions thorough history should review psychological stressors, abuse, or dietary patterns that include caf-feine or liquids before bed. Javier's mother states he has “never been dry at night but has been toilet‐trained during the day-time for 2 years. ” Because enuresis refers to involuntary urinary incontinence beyond the expected age of 4 years for daytime dryness and 5 years for night dryness, Javier is within the normal age range for his bedwetting to be considered nonpathologic. What is the plan of treatment, referral, and follow‐up care? The plan of treatment would be to provide counseling and reassurance for the family after ruling out any other physiological, psychological, or organic causes of bedwetting. The health care pro-vider can reassure the family that Javier is developmentally appropriate for his age. Bedwetting is more frequent in boys than girls, and 5%-10% of children have primary nocturnal enuresis (PNE) at age 5. It is important to emphasize that Javier might be experiencing stress and embarrassment related to his bedwetting and that this is exacerbated by teasing from his sister, being spanked for wetting the bed by his father, and seeing his mother's frustration. Parents should avoid punish-ment and criticism of a child's bedwetting and provide positive reinforcement when the child has a night without wetting the bed. The health care provider may recommend children's books on bedwetting or making a sticker chart to keep track of dry nights. Javier's mother should be reminded to limit nighttime fluids to 2 hours before bed. She can also ensure that Javier has easy access to the toilet. The family can be helped to set a goal for Javier to use the toilet when he has to go to the bathroom at night, rather than staying dry all night. Based on history and physical exam, Javier does not need a referral at this time. Telephone follow‐up can be conducted with Javier's family to monitor progress over the course of the next year until his 5‐year‐old well‐child visit. His family should be encouraged to come to the office sooner as needed for signs and symptoms of illness. For children with true enuresis, there are several options that can be used in the treatment of this condition, such as bedwetting alarms or medications. Bedwetting alarms work best with children 7 years or older and can be very effective. The alarm conditions the child to get up to use the toilet in order to avoid the alarm going off. They must be used every night for 3-4 months, the family must be counseled on proper use, and the family must wake the child if the child does not awaken to the noise of the alarm. Medications can also help to manage enuresis. First‐line treatment is desmopressin acetate vaso-pressin (DDVAP) in children ages 7 years and older to reduce the volume of urine produced at night. In patients with nocturnal enuresis and daytime incontinence or those who fail with DDVAP alone, adding anticholinergic agents such as oxybutynin chloride or imipramine, a tricyclic antidepressant, in children age 6 years and older can be helpful in reducing uninhibited bladder contractions. Children older than 6 years may also benefit from complementary medicine including chiropractic care, melatonin, acupuncture/acupressure, hypnosis, and biofeedback, although there is limited evidence of the success of these interventions. Daytime wetting can also be a stressful issue for children. Its origin can be neurologic, anatomic, muscular, or functional, which results in problems with storage or emptying of the bladder. Similar to nocturnal enuresis, a full workup should be done to determine the cause. Daytime enuresis is treated with the same medications and behavioral strategies as nighttime enuresis. Does this patient's psychosocial history affect how you might treat this case? In Javier's situation, the health care provider should reinforce with the parents and sibling that Javier should not be teased or punished for bedwetting. What if the patient lived in a rural setting? If this patient lived in a rural setting, it might not be convenient for them to return to clinic for a follow‐up visit. Telephone follow‐up with the family to discuss Javier's bedwetting and to evaluate any strategies the family has tried may be more feasible for families living in a rural setting. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Bedwetting 313 Are there any demographic characteristics that might affect this case? There is no racial or ethnic predisposition regarding the development of enuresis. In relation to gender, males are affected more than females. The incidence of enuresis decreases as children age. Javier's mother reports frustration with having to wash sheets frequently and buy new mattresses because of bedwetting. Considering the socioeconomic status of the parents, it is possible that this is causing additional financial strain for the family. As the provider, you can suggest plastic cover-ings for the mattress or plastic reusable underpads to protect the mattress from getting wet, as well as absorbent briefs for Javier to wear at night. REFERENCES AND RESOURCES Cheer, B. (2019). In review: Children with nocturnal enuresis. Nursing in Practice: The Journal for Today's Primary Care Nurse, 108, 30-32. Jabbour, M., Abou Zahr, R., & Boustany, M. (2019). Primary nocturnal enuresis: A novel therapeutic strategy with higher efficacy. Urology, 124, 241-247. Kamperis, K., Hagstroem, S., Faerch, M., Mahler, B., Rittig, S., & Djurhuus, J. (2017). Combination treatment of nocturnal enuresis with desmopressin and indomethacin. Pediatric Nephrology, 32, 627633. Kuwertz‐Bröking, E., & von Gontard, A. (2018). Clinical management of nocturnal enuresis. Pediatric Nephrology, 33, 1145-1154. Siddiqui, J., Qureshi, S., Allaithy, A., & Mahfouz, T. (2019). Nocturnal enuresis: A synopsis of behavioral and pharmacological management. Sleep & Hypnosis, 21, 16-22. St‐Jean, A. (2018). Chiropractic care of a 10‐year‐old female with primary nocturnal enuresis: A case report. Journal of Clinical Chiropractic Pediatrics, 17, 1490-1495. Waters, K., Prentice, B., & Caldwell, P. (2017). An exploratory study of melatonin in children with nocturnal enuresis. Australian & New Zealand Continence Journal, 23, 15-18. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
315 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Are there any laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for a burn? There are no recommended laboratory or imaging studies for a burn such as the one described in the physical examination. What is the most likely differential diagnosis? Partial thickness burn: When examining a pediatric patient with a burn, it is important to determine the thickness of the burn. Older descriptions of burns were first, second, or third degree. Now burns are classified as superficial, superficial partial thickness, deep partial thickness, and full thickness injuries. Superficial burns (first degree) affect only the surface of the skin (epidermis). The skin will be ery-thematous and painful but will not develop blisters. Superficial burns usually tend to heal within 1 week without scarring. A partial‐thickness (second‐degree) burn damages not only the epidermis but extends down into the dermis. These burns will typically be painful. Partial‐thickness burns are subdivided into two categories: superficial partial‐thickness burns and deep partial‐thickness burns. Superficial partial‐thickness burns develop blisters within approximately 2 to 3 weeks. Superficial partial‐thickness burns usually heal without significant scarring. Deep partial‐thickness burns are at risk for significant scarring due to the depth of the injury. Healing time for deep partial‐thickness burns is weeks to months. Full‐thickness burns (third degree) require an exten-sive healing time if not excised and grafted. Full‐thickness burns may not be painful because the nerves are damaged. These burns have a poor cosmetic outcome. Based on the history and physical examination, it appears that Faye has a partial‐thickness burn to her right hand. What is your plan of treatment, referral, and follow‐up care? Immediate treatment of the injury in the home environment should be documented. It is preferable to cool a partial‐thickness burn for approximately 20 minutes to diminish the burning of the skin. Evaluation of a burn includes an investigation as to the type of heat source, estimation of tempera-ture, and duration of contact. Ascertaining this information may give insight into the depth of burn. Case 3. 3 Burn | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
316 Resolutions The initial management of a burn involves determining the burn depth and total body surface area (TBSA) affected. Only partial‐ and full‐thickness burns are included in the calculation. The TBSA may be calculated using either the rule of nines burn chart (Table 3. 3. 1) or the Lund and Browder burn chart (Tables 3. 3. 2 and 3. 3. 3). For the pediatric patient, the Lund and Browder burn chart is preferred. Calculating the percentage of TBSA affected is important when deciding the need for hospitalization versus outpatient management. Criteria for determining whether a burn can be treated at home vary based on the experience and resources of the treating health care center. Burns that may be treated on an outpatient basis include those that affect less than 15% TBSA and those that have no airway involvement. The ability of the child to drink and tolerate oral fluids and having a dependable family able to transport the patient for clinic appointments are also key factors. If the burn is the result of suspected abuse, the patient may not be treated on an outpatient basis. For small burns, a rough estimate of the affected BSA can be made by comparing the burn with the size of child's palm (which represents approximately 1% of the BSA). Since Faye's burn is only on her right palm, it is estimated that her burn represents only 1% of her TBSA. Although the burn represents only a minute portion of Faye's TBSA, all burns of the hands, mouth, or genitals require immediate medical attention. Hand burns are susceptible to functional limitations, as a consequence of scar formation and contractures. The treatment of hand burns in the pediatric patient should involve careful follow‐up to gauge not only the healing and restoration of function to the hand but Table 3. 3. 1. Rule of Nines Burn Char t. Percent of Body Surface Area Body Part Infant Child Adolescent/Adult Head 18% 13% 9% Anterior trunk 18% 18% 18% Posterior trunk 18% 18% 18% Upper extremity (each one) 9% 9% 9% Lower extremity (each one) 14% 16% 18% Genitalia 1% 1% 1% Table 3. 3. 2. Lund and Browder Burn Char t (Part 1). Body Part Percent of Body Surface Area Head See chart below (Part 2) as this measurement changes with age Neck 1% Anterior trunk 13% Posterior trunk 13% Upper extremity (each one) 5% Buttocks 5% Lower extremity (each one) See chart below (Part 2) as this measurement changes with age Genitalia 1% Table 3. 3. 3. Lund and Browder Burn Char t (Part 2). Age (years) 0 1 5 10 15 Adult 1/2 of head 91/2% 81/2% 61/2% 51/2% 41/2% 31/2%1/2 of one thigh 2¾% 3¼% 4% 4¼% 41/2% 4¾%1/2 of one leg 21/2% 21/2% 2¾% 3% 3¼% 3% | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Burn 317 also to assess for psychological and emotional trauma. Current American Burn Association (2006) guidelines recommend burn unit referral for burns involving the hands. However, many hand burns are treated in primary care settings, such as the emergency room, primary care office, or an urgent care center. Goals of treatment for Faye's partial‐thickness (second‐degree) burn are to reduce pain and pre-vent infection. Pain relievers such as acetaminophen or ibuprofen can help with inflammation and pain and should be used according to directions. Children under the age of 18 years should not be given aspirin for the relief of pain or inflammation because of the risk of developing Reye syn-drome. Topical antimicrobials of choice include bacitracin and neomycin for partial‐thickness burns. Since this is a hand burn at risk for contractures, the primary care health care provider in this case should refer Faye to the local emergency department or to a burn specialist if one is accessible. Faye's mother should be educated regarding the signs and symptoms of infection and when to call or return to the primary care office. She should also be educated about the prevention of burns. Does this patient's psychosocial history affect how you might treat this case? An aspect of Faye's psychosocial history that might affect the handling of her case is that her mother is a teenager. Research has shown that when compared to children of adult mothers, chil-dren of adolescent mothers have an increased rate of unintentional injuries during the first 5 years of life. It would be important to provide extensive education regarding safety to prevent future unintentional injuries. It would also be important to have close follow‐up to ensure that the family follows up as necessary. What if the patient lived in a rural setting? If Faye and her family lived in a rural setting, gaining rapid access to a health care provider skilled in treating hand burns in pediatric patients might be delayed. Also, the family may experience bar-riers in attending follow‐up appointments to monitor the healing. For this reason, if Faye's family lived in a rural setting, she might have to be hospitalized for the initial treatment of her burn. Are there any demographic characteristics that might affect this case? Both age and ethnicity are demographic factors that may affect the incidence of burns in the pedi-atric patient. Children less than 6 years of age are more likely to suffer from burns than children over 6 years of age. This may be due to a natural curiosity on the part of the younger child, coupled with their slower reaction time when contacting a hot object. African American children are most commonly affected by burns, followed by Caucasians, Hispanics, and Asians. Are there any standardized guidelines that should be used to assess or treat this case? The American Burn Association has listed guidelines for the management of burns and burn cen-ters. See the reference listed below. REFERENCES AND RESOURCES Aghaei, A., Soori, H., Ramezankhani, A., & Mehrabi, Y. (2019). Factors related to pediatric unintentional burns: The comparison of logistic regression and data mining algorithms. Journal of Burn Care & Research, 41, 606-612. American Burn Association. (2006). Burn referral criteria. Retrieved from: http://ameriburn. org/wp‐content/ uploads/2017/05/burncenterreferralcriteria. pdf Hawkins, L., Centifanti, L., Holman, N., & Taylor, P. (2019). Parental adjustment following pediatric burn injury: The role of guilt, shame, and self‐compassion. Journal of Pediatric Psychology, 44, 229-237. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
318 Resolutions Nelson, S., Conroy, C., & Logan, D. (2019). The biopsychosocial model of pain in the context of pediatric burn injuries. European Journal of Pain, 23, 421-434. Padalko, A., Cristall, N., Gawaziuk, J., & Logsetty, S. (2019). Social complexity and risk for pediatric burn injury: A systematic review. Journal of Burn Care & Research, 40, 478499. Parrish, C., Shields, A., Morris, A., George, A., Reynolds, E. Borden, L., . . . Ostrander, R. (2019). Parent distress following pediatric burn injuries. Journal of Burn Care & Research, 40, 79-84. Rosado, N., Charleston, E., Gregg, M., & Lorenz, D. (2019). Characteristics of accidental versus abusive pedi-atric burn injuries in an urban burn center over a 14‐year period. Journal of Burn Care & Research, 40, 437-443. Sheckter, C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., & Wang, N. (2019). Increasing ambulatory treatment of pediatric minor burns—The emerging paradigm for burn care in children. Burns, 45, 165-172. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
319 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Unless a systemic infection is suspected, there are no laboratory tests needed for a diagnosis asso-ciated with tooth pain. Imaging studies such as a dental X‐ray will be able to detect caries not visible to the naked eye. What are the most likely differential diagnoses and why? Gingivitis and dental caries: When considering the symptom of tooth pain, there are several differential diagnoses to consider, including gingivitis, dental caries, and periodontitis. Gingivitis is an inflammatory process of the gum tissues surrounding the teeth. With gingivitis, the gingiva (gums) may appear to be erythem-atous and swollen. This is prevalent in people with inadequate oral hygiene, inadequate plaque removal, poor nutrition, and lack of periodic dental examinations. Caries (cavities) are decayed areas of the teeth that develop into openings or holes. Caries are caused by a combination of factors, including not cleaning the teeth well, eating frequent sugary snacks, and drinking sugary drinks. Periodontitis is a serious gum infection that damages the soft tissues and bones that support the teeth. Like gingivitis and caries, periodontitis is usually the result of poor oral hygiene. People who have periodontitis will likely have receding gums. They may also display pus between their teeth and gums. Based on the history of erythematous and edematous gums and holes in his teeth, it would appear that Lamont has both gingivitis and dental caries. He was not reported to have any receding of his gums, so it is unlikely that he has developed periodontitis. What is the plan of treatment, referral, and follow‐up care? Treatment for Lamont's tooth pain related to his gingivitis and caries will encompass several aspects. Proper oral hygiene (including brushing and flossing) should be stressed. Because of a probable lack of hand dexterity in a 5‐year‐old, Lamont's parents should assist him in brushing his teeth at least once daily and flossing the teeth that are in contact with other teeth. Using a power toothbrush with an oscillating motion has been shown to be better at removing plaque than a manual toothbrush. These actions will help to reduce plaque associated with gingivitis and caries. Lamont should use a warm saline rinse several times per day to help resolve his gingival Case 3. 4 Toothache | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
320 Resolutions inflammation. An oral rinse with a hydrogen peroxide 3% solution may also help. Nonsteroidal anti‐inflammatory drugs (NSAIDs) have been shown to assist with the resolution of pain and inflammation associated with gingivitis and caries. Prevention of dental disease through good oral hygiene and regular dental checkups should be discussed with Lamont's parents. Proper nutrition, including foods that do not contain simple sugars, should be stressed. Research has shown that foods containing milk or milk components (e. g., yogurt) may have cariostatic properties. These foods should be encouraged as part of a balanced diet for Lamont. Drinking from the bottle should be discontinued. Lamont should be referred to a dentist for a professional cleaning of his teeth and for the management of his caries. He should follow up in the primary care office if his tooth pain worsens or if he develops a fever before his dental appointment. Does this patient's psychosocial history affect how you might treat this case? Children who immigrate to the United States tend to have a higher rate of dental disease and lower rates of dental health care utilization than do children born in the United States. Lamont's family may not have had access to preventive dental care and teaching about good dental hygiene in their home country. In addition, Lamont has a cariogenic diet. His history revealed that he eats quite a bit of junk food. Lamont also still drinks sugary drinks from a bottle. What if the patient lived in a rural setting? Children in rural locations may have decreased access to dental care based on the lack of avail-ability to a nearby dentist. However, research reveals that children in rural settings have fewer cavities than children in urban areas. Are there any demographic characteristics that might affect this case? Preschool age is a common time for the development of dental problems because the responsibility of oral hygiene (such as tooth brushing) shifts to the child. The preschool‐age child does not always have the manual dexterity to brush and floss correctly. Therefore, they are at risk for developing dental problems such as gingivitis and dental decay. It is estimated that 9%-17% of children aged 3-11 years have gingivitis and 70%-90% adolescents have gingivitis. In adults, gingivitis is slightly more common in males than in females, because females are more likely to have better oral hygiene. Are there any standardized guidelines that should be used to assess or treat this case? The American Academy of Pediatric Dentistry has developed guidelines for pediatric dental health. See their reference below. REFERENCES AND RESOURCES American Academy of Pediatric Dentistry (AAPD). (2018). Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Retrieved from: https://www. aapd. org/globalassets/media/policies_guidelines/bp_periodicity. pdf Bidwell, J. (2018). Fluoride mouth rinses for preventing dental caries in children and adolescents. Public Health Nursing, 35, 85-87. Cheng, L. L. (2017). Limited evidence suggests fluoride mouth rinse may reduce dental caries in children and adolescents. Journal of the American Dental Association (JADA), 148, 263-266. Chieh, T., Badger, G., Acharya, B., Gaw, A., Barratt, M., & Chiquet, B. (2018). Influence of ethnicity on parental preference for pediatric dental behavioral management techniques. Pediatric Dentistry, 40, 265-271. Karami, S., Ghobadi, N., & Karami, H. (2017). Diagnostic and preventive approaches for dental caries in children: A review. Journal of Pediatrics Review, 5, 1-7. Ogawa, J., Kiang, J., Watts, D., Hirway, P., & Lewis, C. (2019). Oral health and dental clinic attendance in pediatric r efugees. Pediatric Dentistry, 41, 31-34. Peres, M., Ju, X., Mittinty, M., Spencer, A., & Do, L. (2019). Modifiable factors explain socioeconomic inequalities in children's dental caries. Journal of Dental Research, 98, 1211-1218. Van Malsen, J., & Compton, S. (2017). Effectiveness of early pediatric dental homes: A scoping review. Canadian Journal of Dental Hygiene, 51, 23-29. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
321 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for abdominal pain? An abdominal radiograph may be helpful if constipation is suspected. It may reveal a full rectal vault and fecal loading. There would be no signs of obstruction. A stool test for occult blood would reveal the presence of blood in the stool and may suggest rectal or anal tearing during stooling. Anorectal manometry evaluates internal sphincter relaxation with rectal distention. This test would be used if Hirschsprung disease is suspected. A digital rectal exam should reveal a full rectal vault in functional constipation, while Hirschsprung disease is more likely to present with an empty rectum on physical exam. Patients with constipation and failure to thrive should be evaluated with a celiac panel for celiac disease and a thyroid function test for hypothyroidism. While Jennifer's history and physical are not consistent with Crohn's disease, it would be important to consider this diagnosis if her abdominal pain were persistent and unrelieved by treatment, given the family his-tory for this disease. In a patient with Crohn's disease, ESR may be elevated. An endoscopy and colonoscopy would be warranted if this diagnosis was suspected. What is the most likely differential diagnosis and why? Constipation: While the differential diagnosis for abdominal pain is extensive, it is important to bear in mind that the majority of abdominal pain in children is functional and not the result of an underlying patho-logical process. Included in the differential diagnosis for functional abdominal pain are functional dyspepsia, functional constipation, irritable bowel syndrome, cyclic vomiting syndrome, abdom-inal migraine, and functional abdominal pain syndrome. Organic etiologies of abdominal pain include gastrointestinal infection, anatomic abnormal-ities such as Hirschsprung disease or intussusception, inflammatory diseases such as celiac dis-ease, Crohn's disease, and dietary intolerances. Red flags for organic etiologies of abdominal pain include pain that occurs at night and awakens the child; pain that is distant from the umbi-licus; pain accompanied by fever, dysuria, or hematuria; joint pain or swelling; significant vomit-ing; a change in bowel movement habits; weight loss; or slowed growth. Constipation, with or without abdominal pain, may also be the result of cystic fibrosis, neurological dysfunction, and Case 3. 5 Abdominal Pain | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
322 Resolutions hypothyroidism, which should be ruled out in cases of constipation that do not respond to stan-dard interventions. Given Jennifer's history of increased cow's milk intake, her habit of having a bowel movement only 2-3 times per week, and mild tenderness in left lower quadrant, the mostly likely diagnosis is constipation. What is the plan of treatment, referral, and follow‐up care? Initial management of constipation requires a “cleanout,” which can be achieved using oral or rectal medications, including enemas, osmotic laxatives, stimulant laxatives, and polyethylene glycol. Polyethylene glycol (PEG) and stool softeners are safe and effective for long‐term treatment and should be considered in patients with recurrent functional constipation. PEG is especially useful in the pediatric population, as it is tasteless and can be dissolved easily in any beverage. Because much of the management for constipation involves behavior modification and lifestyle changes, it is important to take the time to educate families. Jennifer's par ents should be educated about constipation, including management guidelines and when to seek medical care. While there is limited support for dietary and exercise interventions for constipation, these lifestyle changes are healthy choices for all patients and may offer some relief for select patients. Jennifer's parents should be encouraged to provide her with a low‐fat, high‐fiber diet and ensure that she gets plenty of regular exercise. Jennifer's mother should be told to decrease Jennifer's cow's milk intake to no more than 24 oz per day since excessive intake of cow's milk has been associated with constipation. Adequate water intake may help prevent constipation as well. In preschool‐aged children with a history of constipation, toileting is often met with fear and frustration. Scheduled toileting can help to normalize toilet time as a relaxing and painless activity. Jennifer's parents should be instructed to have her sit on the toilet for 15 to 20 minutes at a time, 2 to 3 times a day, even if she does not have a bowel movement. Due to the gastrocolic reflex, timing this toileting for 15 to 20 minutes after the completion of meals may prove helpful. During toilet time, Jennifer should sit with both feet firmly on the floor and should be encouraged to relax. A parent should be present with Jennifer during toilet time to provide reassurance and to observe bowel movements. Information obtained about the size and shape of Jennifer's stools can provide both her parents and her health care provider information about the success or failure of her treatment. A reward system (such as a sticker chart) for successful toileting efforts and bowel move-ments may help to encourage future success, while failures should simply be ignored. Based upon the history and physical exam, there is no indication for referral at this time. It is impor-tant that Jennifer and her parents follow up with her health care provider by telephone in 1 to 2 weeks to assess the effectiveness of the recommended interventions. This time will also allow Jennifer's par-ents to express any questions, concerns, or frustrations that may have arisen regarding her symptoms and treatment. The family should follow up in the office in 1 month or sooner if necessary. Prolonged constipation that does not respond to treatment or recurrent abdominal pain that appears to be unrelated to functional constipation may r equire a referral to a pediatric gastroenterologist. Does this patient's psychosocial history affect how you might treat this case? Treatment for constipation does not vary significantly based on psychosocial history, but it is important to bear in mind a family's access to fresh produce, as well as their dietary preferences, when offering nutritional recommendations. Furthermore, constipation may be more prevalent during periods of transition, such as starting school, the arrival of a new sibling, or moving to a new home. When these transitions exist, interventions may require more time before they are suc-cessful. Parents should be encouraged in their efforts, allowed to air frustrations, and offered reg-ular support from health care providers. What if the patient lived in a rural setting? Residence in a rural setting should not affect the treatment of Jennifer's constipation. However, if a more serious etiology were suspected and access to health care were limited by location, more aggressive diagnostics at the time of presentation may be warranted. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Abdominal Pain 323 Are there any demographic characteristics that might affect this case? Constipation is a very common complaint in childhood. In fact, it is estimated that 3%-5% of pedi-atric health care visits are the result of constipation. The prevalence of constipation is equal among girls and boys during childhood, but it occurs more frequently in females than in males following puberty. While constipation occurs throughout infancy, childhood, and adulthood, it appears to be more prevalent during weaning and toilet training, and also in school‐aged children. Many chil-dren with constipation have a family member who also has constipation. REFERENCES AND RESOURCES Bruce, J., Bruce, C., Short, H., & Paul, S. (2016). Childhood constipation: Recognition, management and the role of the nurse. British Journal of Nursing, 25, 1231-1242. Ferrara, L., & Saccomano, S. (2017). Constipation in children: Diagnosis, treatment, and prevention. Nurse Practitioner, 42, 30-34. Howarth, L., & Sullivan, P. (2016). Management of chronic constipation in children. Paediatrics & Child Health, 26, 415-422. Khan, L. (2018). Constipation management in pediatric primary care. Pediatric Annals, 47, e180-e184. Seidenfaden, S., Ormarsson, O., Lund, S., & Bjornsson, E. (2018). Physical activity may decrease the likelihood of children developing constipation. Acta Paediatrica, 107,151-155. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
325 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? To rule out a microbial cause, a swab of the skin under the foreskin and of any discharge should be analyzed for culture and sensitivity. Gram staining may be used to identify the causative microor-ganism and guide treatment. Dark field microscopy may be ordered to observe the presence of spirochetes, specifically Treponema pallidum. A potassium hydroxide test may be performed to look for hyphae if candida is suspected. In addition, a urinalysis should be performed for the detection of microorganisms from the bladder, urethra, meatus, or glans penis and to rule out a urinary tract infection and diabetes. What is the most likely differential diagnosis and why? Balanoposthitis: Conditions to consider in the differential diagnosis of erythema and swelling of the foreskin include balanitis, phimosis, paraphimosis, and balanoposthitis. Balanitis refers to the inflammation of the glans penis. The foreskin is not swollen in balanitis, thus it may occur in both circumcised and uncircumcised males. Balanitis often presents in conjunction with diaper dermatitis. In phimosis, the foreskin cannot be retracted due to adhesion between the prepuce and glans penis, which becomes chronically swollen. This condition is physiologic at birth and should resolve between 3 and 6 years of age. Paraphimosis is a less likely diagnosis for Lydell, but it is one that should be considered for patients with swollen foreskin. In this condition, the foreskin is retracted past the coronal sulcus. Venous stasis results in swelling and pain of the foreskin. Balanoposthitis refers to any infection of the foreskin. Staphylococcus and Streptococcus are the most common bacterial causes of posthitis. Candidiasis is a common fungal origin of posthitis and often occurs in conjunction with fungal diaper dermatitis. In addition, patients may develop irri-tant non‐specific balanoposthitis from poor hygiene, especially related to smegma or prolonged contact with wet diapers. Based on the history and physical examination, Lydell has most likely developed a form of balanoposthitis. Case 3. 6 Lesion on Penis | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
326 Resolutions What is your plan of treatment, referral, and follow‐up care? In addition to Lydell's diagnosis of balanoposthitis, he will likely have a concurrent diagnosis of physiologic phimosis. Because there is no discharge present, it is likely that the cause of Lydell's balanoposthitis is irritation from his diaper. The best treatment for Lydell at this time is a daily bath with a weak salt solution to alleviate inflammation and the application of bacitracin antibiotic ointment to the affected area 2-3 times daily. Lydell's parents should also be instructed to permit him to be without a diaper for 5-10 minutes after each diaper change to allow air to the area and to allow his diaper area to fully dry. His parents should also be told not to try to retract the foreskin fully as this may result in paraphimosis. Lydell's parents should be further educated to reinforce proper hygiene of the genital area. Lydell's family should follow up by phone in 2 days to report progress and healing. They should return to the office if his condition worsens or if there is no improvement in 48 hours after beginning the salt baths and bacitracin treatment. Health care providers should be awar e that circumcision is not a preventative treatment of balanoposthitis in children younger than 3 years old. For chronic or recurrent balanoposthitis, a referral to a pediatric urologist should be considered. Does this patient's psychosocial history affect how you might treat this case? Though Lydell's father is involved in his care, his father does not reside with Lydell. Because there is no male figure directly caring for Lydell, it is important to educate the mother and grandmother in male genitourinary health. Proper hygiene of the glans penis and foreskin should be discussed, emphasizing that Lydell's foreskin will not likely be fully retractable at 2 years of age and that they should not forcibly retract the foreskin under any circumstances. What if the patient lived in a rural setting? Care of balanoposthitis would not change in a rural setting. Education regarding hygiene should be emphasized as before. For patients living in agricultural settings, hand hygiene after contact with animals should be discussed. Are there any demographic characteristics that might affect this case? When considering ethnicity, balanoposthitis has been noted to occur twice as often in African Americans and Hispanics. The difference in occurrence rates compared to Caucasians is likely related to different circumcision rates between the ethnic groups. Age is not necessarily a factor in the development of balanoposthitis. This condition can occur in males at any age, and the etiologies will vary depending on the age of the patient. REFERENCES AND RESOURCES Paquin, R., & Burstein, B. (2017). Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation. American Journal of Emergency Medicine, 35, 1391-1395. Randjelovic, G., Otasevic, S., Mladenovic‐Antic, S., Mladenovic, V., Radovanovic‐Velickovic, R., Randjelovic, M., & Bogdanovic, D. (2017). Streptococcus pyogenes as the cause of vulvovaginitis and balanitis in children. Pediatrics International, 59, 432-437. Toole, K. (2018). Balanoposthitis in a toddler. Urologic Nursing, 38, 237-239. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
327 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 4. 1 Rash without Fever RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Bacterial culture Bacterial culture of the nar es Examination of Tzanck smear Fluorescent antibody testing of smears Fungal culture Gram stain KOH examination Viral cultur e Results of testing: Bacterial culture: Positive for Staphylococcus aureus +/-Streptococcus pyogenes Bacterial culture of the nar es: Positive for Staphylococcus aureus Examination of Tzanck smear: Negative Fluorescent antibody testing of smears: Negative Fungal culture: Negative Gram stain: Gram‐positive KOH examination: Negative Viral cultur e: Negative What is the most likely differential diagnosis and why? Impetigo: Impetigo is the most common bacterial skin infection in children. It occurs most commonly bet-ween 2 and 5 years of age, although it can appear at any age. Impetigo is caused by a superficial bacterial invasion of the epidermis via breaks in the normal skin barrier. Although Streptococcus pyogenes was once the leading cause of impetigo, the incidence of Staphylococcus aureus has risen steadily since the 1980s, and the majority of cases of childhood impetigo are now caused by Staphylococcus aureus. Methicillin‐resistant Staphylococcus aureus (MRSA) accounts for up to 80% of | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
328 Resolutions all cases of impetigo in some areas of the country. Most of these strains are community acquired and often affect healthy children with normal immune function, whereas historically MRSA is typ-ically seen in hospitalized patients. Children are most often infected by direct contact with infected individuals, but fomites also pose a risk of infection spread. Classic impetigo begins as erythematous macules or papules that quickly evolve to become ves-icles with fragile roofs. The vesicles easily rupture, and the fluid inside dries to form honey‐colored crusts on the eroded skin. Impetigo most often occurs on exposed areas of skin more susceptible to trauma, such as the face and extremities. The incidence is greatest in the summer months. Superficial breaks in the epidermis predispose an individual to develop impetigo. For that reason, impetigo frequently occurs overlying insect bites, atopic dermatitis, and other conditions that lead to skin abrasions. The differential diagnosis includes atopic or other forms of dermatitis, herpes simplex infections, a kerion caused by dermatophyte infection, varicella, Sweet's syndrome, scabies, pem-phigus foliaceus, insect bites, ecthyma, discoid lupus erythematosus, and candidiasis. Another form, bullous impetigo, accounts for approximately 30% of all cases of impetigo. Superficial vesicles also occur in bullous impetigo, but they rapidly enlarge to create bullae with sharp margins and no surrounding erythema. The bullae also rupture and develop honey‐ colored cr usts as in classic impetigo. Bullous impetigo is more common in neonates and repre-sents a localized variation of staphylococcal scalded skin syndrome caused by a toxin‐producing form of Staphylococcus aureus. Bullous impetigo typically occurs in areas prone to friction and moisture such as the diaper area, axillae, and neck folds. The differential diagnosis includes second‐degree burns, fixed drug eruptions, immunobullous diseases such as immunoglobulin A dermatosis, bullous pemphigoid, epidermolysis bullosa, and erythema multiforme. Bullous impetigo can be mistaken for cigarette burns, so child abuse is sometimes included in the differential diagnosis. Although a bacterial culture and Gram stain are useful tools in diagnosing impetigo, the diag-nosis can often be made clinically. Bacterial cultures will typically show Staphylococcus aureus with or without Streptococcus pyogenes. In rare instances, Streptococcus pyogenes impetigo can lead to post-streptococcal glomerulonephritis. Bacterial cultures are more useful when nephritogenic strains of Streptococcus pyogenes or drug resistance are suspected in a patient. In one study, carriage of Staphylococcus aureus was reported in the nasal passage of up to 42% of children between 7 and 19 years of age. A higher incidence has been reported in patients who actually have impetigo. Decisions to treat an individual should not be made based on the presence or absence of Staphylococcus aureus in the nasal passage, because a large percentage of unaffected individuals will test positive; and, conversely, an individual with impetigo may not be a nasal carrier. Other sites of the body may less commonly be colonized with Staphylococcus aureus. Rare complications of impetigo include sepsis, osteomyelitis, arthritis, endocarditis, pneumonia, cellulitis, lymphadenitis, toxic shock syndrome, poststreptococcal glomerulonephritis, and gener-alized staphylococcal scalded skin syndrome. If an individual has recurrent MRSA infections, it may be useful to treat the patient and household members with intranasal mupirocin twice daily for 5 days a few times per year in an attempt to reduce the risk of nasal carriage. What the treatment plan for this diagnosis? Impetigo is usually self‐limiting, localized, and heals without scarring, even without treatment. Small patches of impetigo will typically respond to topical antibiotics such as mupirocin applied twice daily for 5-7 days or retapamulin applied twice daily for 5 days. There is now documentation of mupirocin‐resistant strains of staphylococci. Although most topical antibiotics cause at least partial clinical improvement, they may prolong the carriage state of the bacteria on the skin sur-face. Healthy children with impetigo that is widespread or recalcitrant to topical therapy may require oral antibiotics. Preferred oral antibiotics include amoxicillin‐clavulanate, clindamycin, dicloxacillin, cephalosporins, and macrolides. If MRSA is recovered from a culture, bacterial sensi-tivities should guide drug selection. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Rash without Fever 329 What would the appropriate treatment plan for this diagnosis be if the patient were febrile and/or showing other signs of systemic illness? Infants and children with extensive disease, signs of progressive cellulitis, and systemic symptoms may need hospitalization for parenteral antibiotic therapy and close observation. What is the plan for follow‐up care? A follow‐up appointment in 7-10 days to assess response to treatment may be helpful. However, the high rate of cure and low rate of complications related to impetigo may render follow‐up unnecessary except in recalcitrant cases. Are any referrals needed? Not typically, but some serious or special cases (as mentioned above) may need hospitalization. Should the patient stay out of school and/or day care during treatment? If so, for how long? Children should be treated for a minimum of 24 hours before returning to school or other group settings such as day care in order to avoid spread. What, if anything, should be recommended to unaffected household members? It is important to emphasize good hygiene to the patient and family members in order to prevent further autoinoculation and spread to previously unaffected contacts. Good hand washing with antibacterial soap and disinfection of fomites is useful. REFERENCES AND RESOURCES Kosar, L., & Laubscher, T. (2017). Management of impetigo and cellulitis: Simple considerations for promoting appropriate antibiotic use in skin infections. Canadian Family Physician, 63, 615-618. Romani, L., Steer, A., Whitfeld, M., & Kaldor, J. (2015). Prevalence of scabies and impetigo worldwide: A systematic review. Lancet Infectious Diseases, 15, 960-967. Schachner, L. (2018). Ozenoxacin cream 1% for the topical treatment of impetigo in adults and children is effective & safe & offers advantages vs other antibiotics. Dermatology Times, 39, 41-41. Van Ravenstein, K., Smith, W., O'Connor‐Durham, C., & Williams, T. (2017). Diagnosis and management of impetigo. Nurse Practitioner, 42, 40-44. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
331 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Diagnostic studies to identify a truncal rash can include tests for viruses, bacteria, or fungi. A Tzanck smear of a vesicle scraping would show multinucleated cells if the rash is due to varicella or herpes simplex virus. Additionally, viral culture and direct fluorescent antigen testing (DFA) can be done to differentiate between the two. DFA is more sensitive and much faster than viral culture. If the rash is found to be varicella, polymerase chain reaction (PCR) will assist in determining whether the rash is a wild‐type varicella virus or vaccine‐induced varicella. If there is any suspi-cion of a fungal infection, a potassium hydroxide (KOH) smear test can be performed to assess for the presence of hyphae. However, the description of Aubrey's vesicular rash does not appear to be fungal in origin. In the presence of a sore throat and rash, a bacterial culture for group A beta‐hemolytic streptococcus (GABHS) may be performed. No imaging studies are required. What is the most likely differential diagnosis and why? Breakthrough varicella zoster virus (VZV), also known as chickenpox: Key diagnostic clues are the description of the rash as maculopapular with vesicles; the history of a low‐grade fever, cough, and rhinitis; and the absence of cervical lymphadenopathy. Aubrey did not get her second VZV vaccine, and a single dose is only 70%-90% effective for preventing VZV. As always, other possible diagnoses must be considered. A truncal rash could be shingles, but it is also caused by VZV and only develops after prior infection with chickenpox. Furthermore, the distribution would most likely be limited to one dermatome. Since Aubrey reported a sore throat, scarlet fever associated with strep pharyngitis would be part of the differential diagnosis. However, the scarlet fever rash is often described as a “sandpaper rash,” and lacks vesicles. With Aubrey's symptoms, the rash could also be a viral exanthema. But in the case of a viral exanthema, Aubrey would likely have a more generalized truncal rash. Lyme disease, with its classic “bull's‐eye” rash, must be considered—but this rash is not vesicular. Finally, tinea corporis would be a possible diag-nosis; however, Aubrey's rash does not have erythematous raised edges or central clearing as is common with tinea infections. Case 4. 2 Rash with Fever | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
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