Case Study

Unfolding Case Study

Instructions:  This is a case study that will address common conditions you will see in the outpatient setting. Please read the scenario and answer the questions in the space provided. Be sure to use evidence-based literature to support your responses and create a reference list that should follow the case study. 

Scenario: Ihuman: Emma 

Lianne Pierce is an 18-month toddler, in your office to be seen. Mom reports that she has had a slight cough, runny nose and has been running a low-grade fever. When you ask for the range of temperatures mom responded I didn’t take her temperature, but she felt warm.  Mom reports that she is a bit fussier but is eating and is easy to engage in play. Mom comments that her fussiness may be due to being tired at the end of the day. She is sleeping through the night and has at least 6 wet diapers per day. Mom wanted you to check Lianne because she has had a series of “colds” over the past few months now that she is in daycare. 

Family Medical History:

MGM: 51 yr. (A&W)

MGF: 50 yr. (high cholesterol)

PGM: 48 yr. (breast cancer)

PGF: 50 yr. (A&W)

Mother: 27 yr. (A&W)

Father: 27 yr. (A&W)

One brother: 8 yr. (A&W)

Physical Examination:

Vital Signs: Temperature: 99.8°F (tympanic); pulse: 98 beats/min; respirations: 28 beats/minute

Weight:  25 lbs. 5 oz 

General:  Well nourished, well developed; in no acute distress; appears stated age

HEENT:  Normocephalic without masses or lesions; pupils equal, round, and reactive to light; extraocular movements intact; moderate amount of clear discharge present in both eyes; no redness of conjunctiva; nares patent and noninjected; throat without redness or lesions; right tympanic membrane noninjected, cone of light is slightly diffuse, mobility 4+/4+ which is also mildly red,  left TM with bubbles apparent; mobility 2+/4+; very mild redness at the periphery only; cone of light diffuse

Neck:  Supple without thyromegaly or adenopathy

Thorax:  Clear to auscultation and percussion

Heart:  Regular rate and rhythm; no murmurs, rubs, or gallops

Gastrointestinal:  No hepatosplenomegaly; abdomen soft, nontender; bowel sounds normoactive

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ALSO READ: EVIDENCE BASED PRACTICE

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1. Based on the above scenario what is your initial impression of Lianne’s health condition? (3 points) Explain your response. ----HAS Otitis media

2. What will you do next (this action should be in alignment with your discussion in question #1)? (3 points)

Treatment: Amoxicillin X 7 DAYS. DOSE IS CALCULATED ACCORDING TO CHILD’S WEIGHT

-REMIND PARENT TO ENCOURAGE PO FLUIDS

-SHOULD WATCH FOR ADVERSE EFFECT FROM AMOXICILLIN

-F/U IN 1 WEEK AFTER ABX DOSE

3.  Although not a direct cause of OM, certain other conditions can increase the probability of OM.  List at least 4 conditions that can contribute to the development of OM and provide the pathophysiology (e.g. how does this condition lead to the development of OM).  (10 points)

Viral Rhinitis 

Cold, sore throat, respiratory infection, GERD, COVID-19

Ongoing Scenario: (Lianne is now 5 years old) IHUMAN: Olive Chaney

“Lianne has been sick for about 4 days.  It started with a headache, but she has been complaining of headaches lately anyway, so I didn’t think much of it.  Then she got a sore throat and runny nose.  Now she feels like she has a fever (but I couldn’t find my thermometer since we just moved) and this rash, so I thought I should bring her in.  The rash came on about this time yesterday, and it has not really changed since it started.  She says the rash is just a little itchy.”  Lianne’s mother has made no changes in laundry detergent.  Lianne has not eaten any new foods recently.  Denies known exposure to anyone with chicken pox or any other rash.   You have not seen any similar cases recently in your practice.  Lianne has no history of similar rashes or upper respiratory infections (URIs). Her appetite is good, eats most things. Not a lot of junk foods given, has three meals and two snacks per day. Drinks 3 cups of mild per day. 

Social History:

Lives with mother.  Spends every other weekend with father (parents are divorced) in a city with a population of 30,000 about one half hour away.  Mother is an accountant.  Father is an administrator of a public social service agency.   Parents have been divorced for about 2 years.  Lianne is in the first grade; doing well.  Sleeps well.  No behavior problems.  

Medications:

None

Allergies:

None

Physical Exam:

Vital Signs:  Temperature:  100.8°F (oral); pulse: 96 beats/minute; respirations: 26 breaths/minute

Height:  46” (at the 5-year well child visit); Weight: 42 lbs.

General: Well nourished, well developed; in no acute distress

Skin:  Confluent maculopapular rash; no pustules; no desquamation; rash is predominantly over trunk, but there are a few (about 3) vesicles located on the lateral aspect of the upper trunk; vesicles are nonlinear in distribution and are about 6 to 8 cm apart

HEENT:   Normocephalic without masses or lesions; conjunctiva noninjected; pupils equal, round, and reactive to light; extraocular movements intact; nares patent and noninjected; throat with redness and a moderate number of vesicles; tonsils 1+ with no apparent exudate; no petechiae on palate or uvula; teeth in good repair; tongue pink and in the midline; tympanic membranes (TMs) slightly dull and retracted, cone of light slightly diffused, TMs mobile minimally enlarged, anterior cervical nodes palpable; no posterior nodes palpable.

Thorax:  Clear to auscultation and percussion

Heart:  Regular rate and rhythm; no murmurs, rubs, or gallops

Gastrointestinal:  No hepatosplenomegaly; abdomen soft, nontender; bowel sounds normoactive

Extremities:  Femoral pulses 2+; full range of motion of hips

Neurological:  No Babinski signs present

Laboratory/Diagnostics:   

Streptococci screen: Negative

Throat culture: Positive for non-group A β-hemolytic streptococci

4. What is your initial impressions of Lianne’s condition (in other words what disease process do you think she might have)” (5 points) Explain your rationale.

-ROSEOLA

5. A maculopapular rash with a sore throat and fever could also be caused by what pathogens? Explain (8 points). Could Lianne have the disease caused by one of these pathogens? Why or why not? (5 points). 

-Atopic Dermatitis

-Allergic reaction

-Epstein Barr

-Herpes

-Scarlet Fever

-Measles

-Ebola

6. What are your differential diagnoses? How would you rule each one of these differentials out or in) (15 points)? Please provide rationale for each differential and why you would rule it out or in. 

7. What is your diagnosis for Lianne? (5 points) -ROSEOLA

8. What treatment modalities will you initiate? Why? (10 points). 

Ongoing Scenario: (Lianne is now 6 years old) Ihuman Billy Johnson

Lianne is here in the office because her mom was called into Lianne’s school and had a meeting with Lianne’s teacher and the school counselor. They asked that Lianne be evaluated because she is having difficulty in the classroom. She is falling behind on her schoolwork. Mom admits Lianne does not want to go to school, frequently saying she stomach hurts. Mom states this behavior around school is getting worse. She doesn’t have friends, and mom always felt Lianne had difficulty making friends because she was so shy. She had difficulty separating from mom when she was dropped at school. Mom associated this behavior as normal initially, but it has continued now for over a year. While in school Lianne is a loner and prefers to stay indoors while the other children are outside playing. 

Physical Exam:

Vital Signs:  Temperature:  97.8°F (oral); pulse: 64 beats/minute; respirations: 20 breaths/minute

Height:  48”; Weight: 50 lbs.

General: Well nourished, well developed; in no acute distress

HEENT:   Normocephalic without masses or lesions; conjunctiva noninjected; pupils equal, round, and reactive to light; extraocular movements intact; nares patent and noninjected; throat with redness and a moderate number of vesicles; tonsils 1+ with no apparent exudate; no petechiae on palate or uvula; teeth in good repair; tongue pink and in the midline; tympanic membranes (TMs) slightly dull and retracted, cone of light slightly diffused, TMs mobile minimally enlarged, anterior cervical nodes palpable; o posterior nodes palpable.

Thorax:  Clear to auscultation and percussion

Heart:  Regular rate and rhythm; no murmurs, rubs, or gallops

Gastrointestinal:  No hepatosplenomegaly; abdomen soft, nontender; bowel sounds normoactive

9. What are your impressions of Lianne’s behavior? Why? (5 points).

Ongoing Scenario: (Lianne is now 12 years old)

Lianne is here for a sports exam; mom feels that if Lianne gets involved in a sport she loves she might be able to make friends. Lianne is also excited that she made the swim team and will probably compete in the 100-meter free style.  She is still in Tanner stage 1 for breast development and public hair development.  Mom did mention that she (mom) started her menses at age 12, mom asked if she could expect the same for Lianne. 

10. What is your response to mom regarding Lianne’s sexual development? (3 points).

11. Certain sports lend themselves to teenagers engaging in unhealthy dietary practices. Name at least 5 sports associated with unhealthy dietary practices. (5 points). 

1. Gymnastic
2. Wrestling 
3. Swimming
4. Bally Dancing 
5. Track Running 
6. Body building

Ongoing Scenario: (Lianne is now 17 years of age).

Lianne is in your office for an exam. Her major concern is that she has not had a period for at least three months, but she isn’t sure. She is not on any birth control and she is sexually active with her best friend. According to Lianne’s history, she did not begin having periods until six months ago, and she has not had regular periods. She knows she is not pregnant as her partner is a female best friend. She tells you that she is still on the swim team and works out daily, which is in addition to her daily swim practice. 

12. What additional history questions would you like to ask her? (5 points)

1. How is diet
2. How many hours do you exercise? 
3. Have you noticed any changes in your weight? 
4. When last menstrual cycle 

13 What laboratory/diagnostic tests would you like to order and why? (10 points) 

1. Thyroid
2. CBC
3. Albumin/pre-albumin levels 
4. BMP
5. Estrogen level

You do a physical exam on Lianne and notice her BMI is below the normal BMI for age and height. When you do a 24-hour recall of her caloric intake you notice is she consuming about 500 calories per day. 

14.  What do you suspect is going on here and why? (4 points)

-Consuming 500 calories per day is not a healthy meal. These calories are too little that

the body is gradually getting into starvation. As an athlete, her body requires excessive energy therefore, the

energy is being used up in training depleting any that would have been utilized in producing

estrogen that is necessary for period production.

15. What is your diagnoses and what will you do next? (4 points)

-Aneroxia