Individual Case Study

Subjective Data

J. F. is a seven-year-old boy who was brought to the office on June 6th, 2016 at 12:20 pm by his mother and accompanied by his two siblings. His chief complaint was a runny nose and cough. The boy’s mother noted that J. F. had been coughing and had a congested chest for the last four days. According to the mother, J. F had not been exposed to any new foods or environments recently. In addition, the boy had not been exposed to anyone ill within the last few days.

The boy’s past medical history includes children’s Motrin 10ml P.O. Q that he had been taking after a 6-8 hour interval for a headache and fever. Children’s motrin, also known as ibuprofen, is an analgesic that is administered 5-10 mg/kg. The drug inhibits cyclooxygenase-1 and 2 enzymes, resulting in reduced formation of prostaglandin precursors. The drug also has analgesic, as well as anti-inflammatory properties (Sullivan et al., 2011). Oral administration is recommended for children less than eleven years old, so it is suitable for J. F. The child has no history of allergies or hospitalizations. However, he was diagnosed with asthma when he was three years old. Furthermore, the boy does not have a history of chronic illnesses, major traumas or medication intolerances.

Family history indicates that the boy’s mother is 35 years old and is a healthy individual. The father is a 40 year old healthy man. In J.F’s family, there are two other boys who also have a history of asthma. Social assessment showed that the boy lives at home with his parents and the two siblings. At school, the boy plays soccer. In fact, he has a lot of friends and he likes being at school. The boy has received all of the immunizations which are appropriate for his age.

Review of Systems

The general review found that the patient had lost appetite and felt tired but had been drinking fluids to get better. He had been having fever for the past three days, and during that time, his mother gave him Motrin which is an over-the-counter medication. Cardiovascular examination revealed no chest pain. The boy denied any legs swelling and had no rapid weight gain. His skin was intact and without any rashes. He had no bleeding or skin discolorations.

Respiratory assessment recorded no complaints of SOB, but he had a cough that was intermittent and, at some point, productive for clear to white secretions. He denied hemoptysis or green-color sputum. However, it was evident that the boy was asthmatic but had neither required intubation, nor had he been hospitalized for it. The eyes did not require corrective lenses and he did not complain of blurred vision. The assessment recorded that the patient did not have any visual changes.

Gastrointestinal assessment recorded no loss of appetite. He also denied being nauseous or vomiting or diarrhea. He denied abdominal pain, constipation or traces of blood in the stool. The ears were not hurting, neither did he have a hearing loss. There was no ear discharge. Genitourinary examination was not urgent, but there was no change in color of his urine. Nose, mouth and throat examinations revealed no problems with sinus. There was also no dysphagia, nose bleeds or discharge. The child did not have throat pain. Musculoskeletal assessment recorded no joint pains, but the patient stated that he was just feeling tired. He died having been injured, but having no joint pain or any deformity in his muscles. During the examination, it was revealed that breasts were symmetrical to lumps and there were no lumps. Neurological assessment revealed that there were no seizures, paraesthesia or black out spells. Heme assessment found no masses or bumps on the patient’s body. Finally, his psychiatric recorded no anxiety or difficulties falling asleep.

Initial Differential Diagnoses

Objective Data

Weight   

Body Mass Index (BMI)   

Blood Pressure (BP)

Height     

Pulse  

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Resp

Generally, the seven-year-old patient appeared healthy without acute distress. He was alert and oriented. He also answered the questions he was asked during the assessment very appropriately. However, he appeared to have a slight somber affect during the initial contact, but it later became brighter. The patient’s skin was warm, dry, clean and intact. There were no rushes or lesions during the assessment.

HEENT examination recorded the head as normocephalic without any deformities. He did not have head injuries, lesions or masses. His hair was distributed normally and appeared even. The face was symmetrical without notable drooping or trauma. There was no TMJ click and there were also no frontal or maxillary sinus tenderness or pain. The ears appeared even without the notable masses or growths. The boy’s ear canals were clear with mild cerumen in the left ear. The tympanic membrane was bilateral without erythema, effusion or drainage.

For PERRLA assessment, it was recorded that there was no examination of mouth, while eyes had no drainage. The left nare passage was not patent. Similarly, there were no septal deviations or polyps. The bilateral nasal erythema had a clear nasal discharge. His dentition was in a good condition and without any cavities. There was no tongue deviation, masses or notable lesions. The mucous membranes were pink and moist without lesions or masses. The tonsils were bilateral +1, without erythema, exudates or petechial noted in the throat.

Cardiovascular assessment recorded both S1 and S2, while sitting up and laying down; however, there were no S3 and S4. Likewise, there were no murmurs. PMI and RRR were without displacement. There was no notable cyanosis, while capillary refill took less than 3 seconds in all the extremities. Importantly, bilateral radial, femoral, brachial, as well as pedal pulses were +3, but there was no edema or swelling. 

His gastrointestinal was flat, symmetrical and without any scars. There were no lesions recorded. There were active bowel sounds; however, the sounds were without bruits. The gastrointestinal was soft and non-tender to both normal and deep palpitations. There were no masses or organomegaly noted during palpitation. The breasts were symmetrical to lumps and did not have bumps. There was no urgency for genitourinary examination and the color of his urine did not change. Musculoskeletal examination revealed no joint pains, though the patient noted that he felt tired. He denied injuries, pain, as well as deformity of joints or muscles. The young boy had no seizures, paresthesias or spells of black out. Psychiatry examination revealed no anxiety or sleeping difficulties.

Special Tests

A rapid strep test produced a negative result. The test is often performed to determine if a child’s sore throat has been caused by a strep infection or other germs, particularly viruses that do not require antibiotic medication. Strep throat is very common in children between the ages of 5 and 10 years old, therefore, it was deemed necessary to conduct the test.

Diagnosis

Upper respiratory infection (URTI)

This has been considered among the most common medical conditions that are encountered in people’s daily lives. It presents an acute febrile with the symptoms of cough, sore throat, coryza, and hoarseness (Rohilla, Sharma, & Sonu, 2013). It is important to note that the problem is transmitted through aerosol, droplet, or making direct hand contact with those who are affected. Subsequent passage to the nares or eyes has been reported as critical ways of acquiring the infection (Bosch, Biesbroek, Trzcinski, Sanders, & Bogaert, 2013).  

The patient is suffering from URTI because his chief complaints, notably, runny nose and cough, are important symptoms that have been reported in patients suffering from the problem.

Differential Diagnoses

1. Bronchitis

Bronchitis occurs when the bronchi are irritated and become inflamed. The symptoms include coughing that may be accompanied by yellow-grey mucus. The condition also results in sore throat, as well as wheezing. Even though the patient was coughing, he did not complain of wheezing (Jackwood, 2012). He also denied yellow-grey mucus; therefore, he could not have been suffering from this condition.

2. Asthma Exacerbation

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This condition consists of acute or subacute episodes that worsen progressively. It is characterized by coughing, breathlessness, wheezing as well as chest tightness. Signs include increased rate of respiration, agitation, increased pulse rate, as well as reduced lung function. The patient was not suffering from this condition because he did not complain about the signs and symptoms associated with this condition apart from coughing.

3. URI Bacterial 

Beta hemolytic streptococci are known to cause this condition (Sarrell & Giveon, 2012). However, laboratory examination for strep returned a negative result, meaning the patient is not suffering from the condition (Sarrell & Giveon, 2012).

4. Pneumonia

This is characterized by breathlessness, cough, fever, sweating, poor appetite, and chest pain (Metersky, Masterton, Lode, File, & Babinchak, 2012). Apart from cough, the boy did not complain of other symptoms associated with pneumonia, therefore, he could not have been suffering from it.

5. Allergic Rhinitis

The condition is associated with inflammation of the inside of nose due an allergen. Symptoms of rhinitis occur whenever patients breathe things that they are allergic to. In this case, the boy was not found to have a history of allergy; hence, he could not be suffering from the condition.

Plan 

  • The patient should be administered brompheniramine/phenylephrine, usually helpful in case of cold or allergy. It should be administered in 10ml Q4h PRN.    
  • Children’s Motrin 10ml P.O Q 6-8 hours should be continued for fever and headache.
  • Albuterol 2.5 mg NEB 4-6 hours can help to reduce asthma symptoms or SOB.
  • Ventolin HFA 90mcg/spray MDI 2 puffs Q4-6 hours can be applied for bronchospasm.
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