NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
iHuman Case of Emma Ryan, 2 year old with chief complaint of runny nose, cough, and fever.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
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During history collection, when going through patient’s symptoms with her mother, I failed to further investigate an ear problem, because patient is a 2 year old, she was not able to communicate and presented with discomfort during visit. I asked about ear pain or discomfort such as the child tugging at her ear and mother replied that there were no signs of that, but I failed to ask if there were any signs of discharge or bleeding of the ears. The collection of these signs are clinically important because that could lead to a better understanding initially, prior to physical exam, as bleeding discharge from the ears can indicate and external ear canal wound, skull fracture, or traumatic perforation of the tympanic membrane (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 127). Discharge of the purulent type can also be a sign of infection or a foreign body in the ear (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 127). Another question that was missed during history collection was if patient had a flu shot. I stopped at asking if when her last immunizations were given and if they were up to date, but failed evaluate mother’s answers further and ask about the flu vaccine. This is very important to assess and document because children are a target population in receiving flu vaccine due to the benefits of reducing rates of pneumonia in children and reducing the incidence of influenza in the community and should be offered to all children older than 6 months that have no contraindications (Seasonal influenza vaccine in children, n.d). NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
During physical exam, I went through all the systems and was able to accomplish the exam with more ease than last week, however, I added a mental state on vital signs that was not necessary and in looking back I understand why it was not necessary since patient is 2 years old, cannot verbally express what she is feeling, and although I can observe that she is awake or alert and in discomfort, it is not necessary in gathering the information needed. Another error in my exam performance that was not a required exam was looking up nostrils, or internal examination. Initially I felt this may be important to check if there were any abnormalities, however, this is an exam that is more appropriate for those experiencing significant nasal symptoms, the internal examination of the nose is best accomplished after asking the patient to blow his or her nose (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 128). I also realize it would not be the most appropriate or comfortable exam for a “fussy” two year old.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text. NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
One key finding when performing the physical exam was rooted in symptom of cough and erythema of the pharynx. Mother reported that she was extremely exhausted from staying up with Emma all night because of the crying and coughing. During exam, a point of care to further evaluate would be a throat culture to determine if this symptoms was due to an infection such as strep throat and even pharyngitis. According to the Centers for Disease Control and Prevention (2018), conditions such as strep throat is most common in children ages 5-15 years old and rare in children younger than 3 years old, but Emma is in daycare, which increases the possibilities of contracting streptococcus infection.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
On identification of the problem categories, my selection based on the information from history collection and physical exam and assuming that there was an infection present, I selected immune systems as the problem category which was incorrect. After carefully reviewing it and feedback received, I realize that I was getting ahead of myself and not thinking systematically and selecting the correct problem category which was respiratory due to the erythema and bulging of the tympanic membranes and pharynx along with other signs that belong to the respiratory system. This step made me realize that I need to follow the process and not jump to the answer so fast without looking at all the other factors present.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
A missed differential diagnosis that I failed to add was laryngotracheobronchitis or croup. This condition is characterized by a “barking” cough and labored breathing or stridor. On history collection and physical examination, mother reported no labored breathing of difficulty breathing and I failed to explore any defining characteristic of the cough experienced and therefore did not think of adding this differential diagnosis. However, those affected by “croup” show an inflammation of the larynx, throat, and upper bronchial tubes causing hoarseness, cough, which could easily be experienced by our patient Emma, and those affected are children between the ages of six months and five years, but two-year-olds seem to be the most commonly affected (Henningfeld, D. P., 2013). NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
Centers for Disease Control and Prevention (2016). Group A Streptococcal Disease. Retrieved from: https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html
Goolsby, Jo, M., Grubbs, Laurie. (2014). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780803645011/
Henningfeld, D. P. (2013). Croup. Magill’S Medical Guide (Online Edition),
Seasonal influenza vaccines in children. (n.d).
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Does she have discharge or bleeding from her ears?
I did not ask about this because I had asked about whether the child was tugging at her ears and the Mother stated the child was not showing signs of ear discomfort. Discharge or bleeding is clinically significant because that could lead to a better understanding initially, prior to physical exam, as bleeding discharge from the ears of the purulent type can be a sign of infection. The risk for complications associated with otitis media increases if an acute episode of otitis media persists longer than 2 weeks or if symptoms recur within a 2-to 3-week period (Eaton, 2017).
Any new or recent change in medications?
Medication histories are important in preventing prescription errors and consequent risks to patients (Fitzgerald, 2009).
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
I did not have any errors in the physical exam. I did provide a few parts of the exam that were not required such as an SPO2 and a BP.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text. NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
One key finding was bilateral tympanic erythema and bulging. Looking in the ears with an otoscope was vital to visualizing these findings and diagnosing the patient with acute otitis media.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
I originally felt that the patient’s symptoms of erythema and exudate on the pharynx pointed to strep throat and the otitis media was secondary to a strep infection. The expert stated the fever was the main problem and the other symptoms were related.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
One of my missed differential diagnosis was laryngotracheobronchitis or croup. This condition is characterized by a “barking” cough and labored breathing or stridor. On history collection and physical examination, I did not get the impression that the patient had any of these symptoms. However, those affected by “croup” show an inflammation of the larynx, throat, and upper bronchial tubes causing hoarseness, cough, which could easily be experienced by our patient Emma. It occurs most commonly in children aged between 6 months and 3 years and during the late autumn months (Nierengarten, 2015, p. 31). NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever
References:
Eaton, D. (2017). Complications of otitis media. Retrieved from https://emedicine.medscape.com/
article/860323-overview#a3
Fitzgerald, R. (2009). Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol.
67(6): 671–675. doi: 10.1111/j.1365-2125.2009.03424.x
Nierengarten, M. B. (2015). Diagnosis and management of croup in children. Contemporary Pediatrics,
32(3), 31–33. Retrieved from https://www.thecampuscommon.com/library/ezproxy/
ticketdemocs.asp?sch=suo&turl=https://search-ebscohost-com.southuniversity.libproxy.edmc.
edu/login.aspx?direct=true&db=rzh&AN=107779484&site=eds-live NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever