unfolding case study final-edited

Unfolding Case Study

Bay Path University

06/04/2022

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:

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

The patient is likely suffering from an upper respiratory infection or a common cold. The patient presented with several symptoms manifested in pediatric patients with a common cold. These include low-grade fever, runny nose, and cough (Thomas & Bomar, 2021). The presence of bubbles in the left tympanic membrane indicates otitis media, which develops due to a respiratory infection, sore throat, or a common cold. 

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

When managing the common cold, the main treatment objective is to provide symptom relief. As such, the best approach is to provide supportive measures. Use of saline drops with bub suction may remove nasal secretions. Sufficient intake of fluids and 60 mg of Paracetamol after every four hours can reduce the coughing and fever. Given the mild symptoms, the patient is likely to overcome the infection within a short period. Amoxicillin X 7 Days based on the child's weight is recommended to manage the otitis media, and reduce the risk of any complications. 

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)

OM is a multifactorial condition. There are specific conditions that contribute to the health problem. One of the conditions is laryngopharyngeal reflux (LR). Through upper respiratory infection, there are three mechanisms in which LR is thought to contribute to OM. The first is the noxious effect of acid gastric acid on upper respiratory tract mucosa, leading to an uptick in inflammatory mediators, ciliary dyskinesia, mucus hypersecretion, and swelling. The second mechanism simulates excessive vagal reactivity through stimulating vagus nerve response. The last is by introducing Helicobacter pylori into the upper respiratory tract (Lecheien et al., 2021). Vitamin D insufficiency can also contribute to otitis media. Extant research shows that vitamin D is responsible for inhibiting pro-inflammatory factors such as interferon-gamma and interleukin, which reduces inflammation during infection, and, therefore, could prevent the obstruction of the Eustachian tube (Mandour et al., 2021).

Additionally, vitamin D enhances the production of cathelicidin peptides, defense peptides, and antimicrobial peptides, decreasing susceptibility to upper respiratory infections responsible for OM (Mandour et al., 2021). Children with asthma are also at risk of OM. It is hypothesized that inflammatory processes associated with asthma, such as mucosal swelling of the respiratory tract and its inflammation, including the Eustachian tube, increase susceptibility to OM through obstruction or narrowing of the Eustachian tube, which allows for the accumulation and proliferation of pathogens (Kim et al., 2021). 

Ongoing Scenario: (Lianne is now 5 years old)

“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. 

The patient likely has acute pharyngitis. Symptoms of acute pharyngitis include a fever (>100.4oF), sore throat, and runny nose. However, these symptoms do not indicate acute pharyngitis since the symptoms overlap with those of other diseases. A throat culture is critical for clinical diagnosis. Results from the throat culture indicate the presence of non-group A beta-hemolytic streptococci. Non-group A beta-hemolytic streptococci cause acute pharyngitis, and it is difficult to differentiate the causative agent between the two without a throat culture (Gunnarsson & Manchai, 2020). The presence of a confluent maculopapular rash indicates streptococcus-related acute pharyngitis (Pardo & Perera, 2022). 

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 b one of these pathogens? Why or why not? (5 points). 

The other conditions that could lead to similar symptoms include Measles (morbillivirus), exanthema subitum (human herpes virus 6), rubella (Rubivirus), erythema infectiosum (PV-B19), infectious mononucleosis (Epstein - Barr virus), mycoplasma infection (mycoplasma pneumoniae bacteria), and eruptive pseudoangiomatosis (viral pathogen of unknown origin) (Philopena, Hanley, & Dueland-Kuhn, 2020). It is unlikely that any of these pathogens could have contributed to the condition. In patients with measles and rubella, the rash first manifests on the face before spreading to extremities and the trunk. In exanthema, the rash begins after the fever's end (Philopena, Hanley, & Dueland-Kuhn, 2020). On the other hand, when a patient has erythema infectiosum, the rash will first appear in the cheeks as a raised rash before spreading to the buttocks and extremities. On the other, the rash in patients with acute infectious mononucleosis will emerge when the patients receive beta-lactam antibiotics (Philopena, Hanley, & Dueland-Kuhn, 2020). Patients with eruptive pseudoangiomatosis will develop a spontaneous papule that appears as a rash but resolves spontaneously (Philopena et al., 2020). 

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. 

The main differential diagnoses are Roseola, measles, scarlet fever, and the fifth disease. 

Roseola manifests in the form of mild sore throat, high fever, conjunctivitis, and rhinorrhea. Patients with the disease develop tiny erythematous papules on the trunk, which spread to the extremities and the neck (Philopena, Hanley, & Dueland-Kuhn, 2020). Lianne does not have conjunctivitis or rhinorrhea, which means that she does not have roseola. On the other hand, the signs and symptoms of measles include mild fever, cough, koplik spots, conjunctivitis, coryza, and cough. The second stage symptoms of the disease include a maculopapular rash that begins in the head before spreading to the trunk and extremities (Philopena et al., 2020). Lianne does not have koplik spots, which are critical for a measles diagnosis. In contrast, scarlet fever is characterized by a fine erythematous popular eruption, followed by sore throat and fever. The fifth disease has the following symptoms, which last four to 21 days. These include malaise, fever, and red ‘slapped’ cheeks. Patients with the condition also develop a lacy and pruritic rash that spans soles and palms.  The throat culture did not show the presence of group A streptococcus species, which are responsible for the development of scarlet fever.  All the selected illnesses manifest the same exanthem characteristics, and sore throat and fever, hence their inclusion (Philopena, Hanley, & Dueland-Kuhn, 2020).   

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

The diagnosis for Lianne is Non-Group A streptococcus-induced acute pharyngitis. The symptoms of the majority of upper respiratory infections overlap. As such, clinical diagnosis can be established through a throat culture. The culture indicates the presence of a non-group A Streptococcus spp. Furthermore, the symptoms of the patient suggest potential streptococcus acute pharyngitis. The patient has a sore throat, a cough, and a maculopapular rash suggesting the presence of the pathogen. 

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

The treatment modalities to initiate include 250 mg penicillin 2 to 3 times daily for ten days if the patient weighs less or equal to 27 kg, or 500 mg twice daily if the patient is over 27kg in weight. Penicillin is particularly suited for problem management, given its low adverse effect burden and low cost (Ashurst & Edgerley-Gibb, 2022). Generally, antibiotics are often recommended to treat group A beta-hemolytic streptococcus. However, non-group A can also contribute to the problem. The treatment of non-group A beta-hemolytic streptococcus pharyngitis is similar to group A hemolytic streptococcus acute pharyngitis. As such, antibiotics are the first line of treatment for streptococcus-induced acute pharyngitis (Ashurst & Edgerley-Gibb, 2022). While the disorder is self-limiting, antibiotics will limit the healing duration by 16 hours. Therefore, it is essential to start antibiotic treatment to limit the infection and reduce potential complications from the disorder. Other potential modalities that could improve the patient condition include:  (a) bronchodilator if the patient experiences difficulty breathing; (b) anti-inflammatory cream, such as dexamethasone to manage the rash, and swellings caused by the rash; (c) antipyretic to manage the fever.

Ongoing Scenario: (Lianne is now 6 years old)

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).

Lianne could be suffering from a separation anxiety disorder. The disorder is common among children who are starting school. The common features of the disorder include excessive distress when separation from attachment figures is anticipated, persistent worry about losing an attachment figure, and complaints of physical complaints such as vomiting, nausea, and stomach aches (Feriante & Bernstein, 2021). Individuals with the disorder are often less than 18 years old, and the condition's disturbances lead to impairment. In the above scenario, Lianne is complaining of stomach aches, fussing when she is being left at school, and failing in her academic work. These symptoms suggest that she could be potentially suffering from the disorder. 

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).

I would respond that: sexual development varies from one person to another, depending on environmental and genetic factors. As such, Lianne may begin her menses at a different age than that of her mom. 

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

The five sports associated with unhealthy dietary practices include gymnastic, wrestling, swimming, athletics, 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)

The additional questions include the following: How is your diet? Are you taking a balanced diet? How many hours do you exercise daily? Have you noticed unexpected weight changes or drop in weight? When was the last menstrual cycle?  Are you currently under any medication? Do you feel you are under pressure or stress?

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

The following tests are important in determining the cause of the amenorrhea: (a) karyotyping to eliminate androgen insensitivity and Turner syndrome; (b) progesterone challenge test to differentiate between estradiol, anatomic, and anovulation deficiency, which lead to amenorrhea; (c) MRI to evaluate the hypothalamic-pituitary tract; (d) adrenal CT and pelvic ultrasound for anatomic defects, such as androgen-secreting tumors and Mayor-Rokitansky-Kauser-Hauser syndrome; (e) LH and FHS for hypothalamic amenorrhea; (f) BMI to determine malnutrition, excessive exercise and anorexia nervosa, or other eating disorders; (g) DHEAS and testosterone tests to rule out hyperandrogenism; (h) thyroid hormone tests to evaluate thyroid function or disfunction, as any thyroid disturbance can lead to amenorrhea; (i) prolactin level test to eliminate prolactinoma as a potential cause of the symptoms; and (j) beta hCG to determine whether she is pregnant (Nawaz & Rogoi, 2020). 

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 doing on here and why? (4 points)

The following tests are important in determining the cause of the amenorrhea: (a) karyotyping to eliminate androgen insensitivity and Turner syndrome; (b) progesterone challenge test to differentiate between estradiol, anatomic, and anovulation deficiency, which lead to amenorrhea; (c) MRI to evaluate the hypothalamic-pituitary tract; (d) adrenal CT and pelvic ultrasound for anatomic defects, such as androgen-secreting tumors and Mayor-Rokitansky-Kauser-Hauser syndrome; (e) LH and FHS for hypothalamic amenorrhea; (f) BMI to determine malnutrition, excessive exercise and anorexia nervosa, or other eating disorders; (g) DHEAS and testosterone tests to rule out hyperandrogenism; (h) thyroid hormone tests to evaluate thyroid function or disfunction, as any thyroid disturbance can lead to amenorrhea; (i) prolactin level test to eliminate prolactinoma as a potential cause of the symptoms; and (j) beta hCG to determine whether she is pregnant (Nawaz & Rogoi, 2020). 

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

Functional hypothalamic amenorrhea. The next step is to recommend that Lianne increase her energy consumption by 45kc/1kg LBM to replenish lost energy reserves during exercise. Recommend a high nutrient diet rich in Vitamins A, E, K, CV, and B, and other nutrients rich in folic acid, iron, zinc, and magnesium. Prescribe D3 as a supplement for the patient (Ryterska, Kordek, & Zaleska, 2021). Also, encourage the patient to seek psychiatric help if she is suffering from an eating disorder. 

References

Ashurst, J., & Edgerley-Gibb, L. (2022). Streptococcal pharyngitis. Treasure Island, FL: StatPearls.

Chonmaitree, T., Jennings, K., Golovko, G., Khanipov, K., Pimenova, M., Patel, J., . . . Fofanov, Y. (2017). Nasopharyngeal microbiota in infants and changes during viral upper respiratory tract infection and acute ottis media. PLoS One, 12(7), 1-12.

Feriante, J & Bernstein, B. (2021). Separation anxiety. Treasure Island, FL: StatPearls.

Gunnarsson, R., & Manchai, N. (2020). Group C beta hemolytic Streptococci as a potential pathogen in patients presenting with an uncomplicated acute sore throat - a systematic review and meta-analysis. Scandinavian Journal of Primary Health Care, 32(2), 226-237.

Kim, S., Kim, H., Min, C., & Choi, H. (2021). Bideractional association between asthma and otitis media in chidlren. Allergy, Astham and Clinical Immunology, 17(7), 1-12.

Lecheien, J., Hans, S., Bobin, F., Calvo-Henriquez, C., Saussez, S., & Karkos, P. (2021). Atypical clinical presentation of laryngopharyngeal reflux: A 5-year old case series. Journal of Clinical Medicine, 10(11), 1-12.

Mandour, Y., Shendy, M., Ramadan, S., Mohammady, A., & Badae, S. (2021). Vitamin D level in children with secretory otitis media. Otorhunolaryngology Clinics: An International Journal, 13(1), 18-22.

Nawaz, G., & Rogoi, A. (2020). Amenorrhea. Florida: StatPearls.

Pappas, D. (2018). The common cold. Principles and Practice of Pediatric Infectious Diseases, 1(1), 199-202.

Pardo, S., & Perera, T. (2022). Scarlet fever. Treasure Island, Florida: StatPearls.

Philopena, R., Hanley, E., & Dueland-Kuhn, K. (2020). |Emergency department management of rash and fever in the pediatric patient (infections disease CME and pharmacology CME). Pediatric Emergency Practice, 17(1), 1-24.

Ryterska, K., Kordek, A., & Zaleska, P. (2021). Has menstruation disappeared? Functional hypothalmic amenorrhea- what is this story about? Nutrients, 13(8), 1-9.

Thomas, M., & Bomar, P. (2021). Upper respiratory tract infection. Treasure Island, FL: StatPearls.