NR 602 Week3 Case Study- Nasal congestion

NR 602 Week3 Case Study- Nasal congestion

NR 602 Week3 Case Study- Nasal congestion

Patient Information:

P.W. 2 month old, Caucasian male

(S) Subjective:

CC: Nasal congestion and cough x 2 days

HPI:

P.W. is a 2 m.o. male who presents with mother for a follow-up appointment. Mother states that the patient was last seen in the office 2 days ago for bronchiolitis. Within the last 24 hours’ mother notes patient’s feedings have improved, and he is having better UOP, with at least 6+ diapers per day. Mother reports that patient’s cough and respirations sound more productive, and patient had spiked a fever of 100.5 last night. Mother gave the patient Tylenol last night and it helped reduce the fever, and the patient has been afebrile today. Mother notes no s/s of respiratory distress, WOB, and has had a normal appetite, but hasn’t been himself lately with low energy. No other sick household members. He is the only child in the household, and is up to date on immunizations.

Current Medications:

Acetaminophen (TYLENOL) 160 mg/5 mL Susp suspension

Allergies: No known allergies.

PMHx: Birth History
•	Birth
		Length: 50.5 cm (19.88″)
		Weight: 7 lb 2.1 oz (3.235 kg)
•	Apgar
		One: 8
		Five: 9
•	Discharge Weight: 6 lb 13.7 oz (3.11 kg)
•	Delivery Method: Vaginal, Spontaneous Delivery
•	Gestation Age: 39 3/7 wks
		Prenatal: Maternal Blood Type A positive   Antibody negative Maternal hepatitis B surface antigen status: negative Maternal HIV status: negative Maternal RPR negative Maternal Rubella negative Maternal Group B strep: negative Hepatitis C Antibody negative CCHD Screen:

 

PMHx: Birth History

• Birth
  • Length: 50.5 cm (19.88”)
  • Weight: 7 lb 2 oz (3.11 kg)
• APGAR
  • One: 8
  • Five: 9
• Discharge weight: 6 lb 13 oz (3.11 kg)
• Delivery method: vaginal, spontaneous delivery
• Gestational age: 39 3/7 wks
  • Prenatal: Maternal Blood Type A positive
  • Maternal hepatitis B surface antigen status: negative
  • Maternal HIV status: negative
  • Maternal RPR negative
  • Maternal Rubella negative
  • Maternal Group B strep: negative
  • Hepatitis C Antibody negative

 

 

PSHx:  None.

Immunization Hx:

DTaP/HepB/IPV 3/12/19

Hepatitis B-3 dose 1/12/19; 3/12/19

Hib PRP-T 3/12/19

Pneumococcal Conj (Prevnar 13) 3/12/19

Rotavirus Pentavalent 3/12/19

Other Screenings:

Review of Nutrition:

Current diet: breast milk

Current feeding patterns: 2-3 hours

Difficulties with feeding? no

Current stooling frequency: 1-2 times a day

 

Soc Hx:

Social Screening:

Current child-care arrangements: in home: primary caregivers are mother and father (married)

Siblings: 0

Parental coping and self-care: doing well; no concerns

Secondhand smoke exposure? no

Fam Hx: None reported.

ROS:

CONSTITUTIONAL: Fever 100.5 last evening

HEENT: Nasal congestion and cough x2 days. Productive cough. Yellow colored drainage.

SKIN:  None reported.

CARDIOVASCULAR:  None reported.

RESPIRATORY: None reported.

GASTROINTESTINAL:  None reported.

GENITOURINARY:  None reported.

NEUROLOGICAL: None reported. 

MUSCULOSKELETAL:  None reported.

HEMATOLOGIC/LYMPHATICS:  None reported.

PSYCHIATRIC:  None reported.

ENDOCRINOLOGIC:  None reported.

ALLERGIES:  None reported.

 O:

Vital signs: HR 155, RR 64. T 98.7 (rectal) Pulse ox 98%

Height 22.5’ (57.15 cm), weight 11 lb 1 oz (5.018 kg), HC 40.6 cm (16″)

BMI: 15.36, weight 25.56%, height 40.52%, HC, 95.90%

PHYSICAL EXAM

Problem focused physical exam:

General Appearance: Healthy-appearing, vigorous infant, strong cry.

Head: Sutures open, fontanelles normal size

Eyes: Sclera white, pupils equal and reactive, red reflex normal bilaterally

Ears: left TM intensely erythematous dull and retracted, RT TM mildly erythematous and dull, Well-positioned, well-formed pinnae

Nose: Clear drainage present

Throat: Lips, tongue, and mucosa are moist, pink and intact; palate intact

Neck: Supple, symmetrical

Chest: Expiratory wheezes throughout all lung fields, RR 60, Pulse OX 98%, lungs clear to auscultation, respirations unlabored, no cyanosis or retractions examined.

DIAGNOSTIC RESULTS: None available.

DIFFERENTIAL DIAGNOSIS:

1. Acute bronchiolitis due to respiratory syncytial virus (J21.0)-Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause of this infection. …
2. Pertussis (A37.90)-Pertussis, also known as whooping cough, …
3. Croup (J05.0)-Croup is characterized by the abrupt onset, most commonly at night, of a barking cough, …

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Questions:

1. How should the APRN teach the parents to manage the child’s symptoms?
2. Fevers in children under 36 months of age can have potentially serious consequences. For a 2 month old infant, which tests should the APRN considering ordering?

 

Johnson, D. W. (2016, Sept 15). Croup. American Family Physician, 94(6). Retrieved from https://www.aafp.org/afp/2016/0915/p476.html

Kline, J. M., Lewis, W. D., Smith, E. A., Tracy, L. R., & Moerschel, S. K. (2013, Oct 15). Pertussis: A reemerging infection. American Family Physician, 88(8), 507-514. Retrieved from https://www.aafp.org/afp/2013/1015/p507.html

Smith, D. K., Seales, S., & Bduzik, C. (2017, Jan 15). Respiratory syncytial virus bronchiolitis in children. American Family Physician, 95(2), 94-99. Retrieved from https://www.aafp.org/afp/2017/0115/p94.html