Case Study 3:
HPI: A father brought his 7-year-old son with a 3-day history of cough. Dad states that his son is coughing up yellow mucus. The boy is afebrile and is sleeping through the night, but the father’s sleep is disturbed listening to his son coughing. Dad says he thinks his son has bronchitis and is requesting treatment.
PE: VS: Temp 98.4, Pulse 76, respiratory rate 18, pulse ox 99%.
HEENT: there is no cervical adenopathy, nasal turbinates are slightly enlarged, and there is moderate clear rhinorrhea.
PULM: lungs are clear to auscultation, patient is able to take deep breaths without coughing.
Post an analysis of your assigned case by using the following:
1) What additional questions will you ask?
o Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds, and so forth that might be pertinent in arriving to your differential diagnoses)
2) What additional examinations or diagnostic tests, if any will you conduct?
3) What are your differential diagnoses? What historical and physical exam
features support your rationales? Provide at least 3 differentials.
4) What is your most likely diagnosis and why?
5) How will you treat this child?
o Provide medication treatment and symptomatic care.
o Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
6) Patient Education, Health Promotion & Anticipatory guidance:
o Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
o Include any socio-cultural barriers that might impact the treatment and management plans.
o Health Promotion:
I. What immunizations should this child have had?
II. Based on the child’s age, when is the next well visit?
III. At the next well visit, what are the next set of immunizations?
IV. What additional anticipatory guidance should be provided today?