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(Solved) Case Study Question: Introduction: is a 10-year-old who presents to the clinic in the care of his mother (MOC).


Case Study Question:

Introduction: O.A. is a 10-year-old who presents to the clinic in the care of his mother (MOC). She states that he has been sick since school started (it is now November) and she thinks he has a sinus infection. The family is established with the clinic and do come in regularly for primary health care.

Chief Complaint

"He has a sinus infection or something."

History of Present Illness

O.A. is a 10-year-old who presents to the clinic in the care of his mother with a complaint of runny nose, sneezing, watery eye, and a dry cough. He has not had a fever with this illness. MOC states that he has been mildly ill since school started 3 months ago but he has "gotten worse" in the past week. The patient denies ear pain, sore throat, or headache. He has not had any vomiting or diarrhea. He has missed one day of school in the past week due to illness.

Past Medical History

Negative for chronic health problems.

There are no known allergies to medications.

Past Surgical History

Inguinal hernia repair age 18 months

Family History

·      Father alive and well; history of asthma and eczema.

·      Mother alive and well; history of seasonal allergies and gestational diabetes..

·      One brother age 8 years, alive and well.

·      No other family members have a significant medical history.

Social History

·      Lives with family in rented home in suburb.

·      No exposures to passive smoke.

·      5th grader, doing well in school

·      Loves all kinds of sports.

Current Medications

None

Physical Examination

BP=100/68

P=100 and regular

RR=16

SaO2=99%

T= 97.5O F/36.4O C

Height 58 inches

Weight 78 pounds

General

Alert, well groomed; in no acute distress

HEENT

Head: Normocephalic, atraumatic; scalp clear

Eyes: clear, PEERLA

Ears: TMs pearly, positive light reflexes; canals clear; few fluid bubbles visible behind TMs

Nose: moderate amount clear discharge bilaterally

Throat: mildly erythematous, tonsils 2+, uvula midline. Discharge noted in posterior pharynx.

Neck

Supple, full range of motion; no lymphadenopathy

Chest

Symmetric, easy respirations bilaterally

Lungs

Equal, mild decrease in air entry in bilateral bases; occasional expiratory wheeze. Occasional dry cough.

Cardiac

Normal S1/S2, no murmurs heard

Abdomen

Non-distended, non-tender. Positive BS x 4

MSK

Moves all extremities with full ROM; climbs onto exam table easily.

Neuro

A & O x 3; cranial nerves II-XII intact. Sensory and motor nerves intact, DTRs 2+, (-) Babinski

Skin

Warm and dry; erythematous, scaling patches in antecubital spaces.

1) What other questions would you have for O.A. and his mother at this point?

2)Given the information about O.A. at this time, what are some likely reasons for the symptoms he is having?

3) In order to provide a thorough health assessment of O.A, what diagnostic tests (if any) would you order for him at this time? What diagnostic tests would you order in the future?


Other Diagnostics

Office Spirometry:

FEV1 >80 percent predicted 

FEV1/FVC >85 percent

Peak Flows=300, 210, 190

 4) In reviewing the findings from his physical examination and diagnostic workup, which results are abnormal?

Of the problems identified for this patient, which is the most concerning?

Thoroughly explain the pathophysiology for each of the problems identified for this patient. What key information would you want to be sure to share with this patient and his mother?

7) What are the 5 primary goals to include in a comprehensive plan of care for this patient?

8) Outline a comprehensive care plan for this patient. Include information related to diet, exercise, medications, additional diagnostic evaluations, and follow-up appointments.

9) In working with this patient, what health consequences would you want to discuss with him and his mother if he chooses to not to engage in the plan you outlined for him?

 


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