Diet: Jason has been a healthy child. He had some initial feeding issues as an infant with excessive irritability causing multiple formula changes. Since then he has had no food allergies or intolerances and eats a fairly well‐balanced diet with the exception of excessive juice consumption.
Elimination: No difficulties.
Sleep: Jason has had difficulty establishing nighttime sleep patterns. He continues to have difficulty with sleep onset, wakes frequently, and goes into his mother’s bed.
Past medical history: Jason was the second child born to a 27‐year‐old mother by vaginal delivery after an uneventful full‐term pregnancy. He weighed 7 lbs 9 oz and had no problems in the newborn nursery (no temperature instability, no jaundice, and no respiratory issues). He was discharged home with his mother on cow’s‐milk formula at 48 hours of age. Jason experienced a head injury with a loss of consciousness at the age of 3 years. His head CT was normal, but he was admitted to the pediatric unit for overnight observation. He has not had any obvious sequelae from this incident. Jason has had no respiratory, cardiac, neurologic, or allergic problems.
Family history: Jason’s mother has history of Hashimoto thyroiditis and depression and is medicated for both of these conditions. She is fairly adherent to her medication regime. She was an average student, graduated from high school, and works as a cashier. Jason’s 33‐year‐old father has a history of substance abuse, depression, and hypertension. He was incarcerated briefly for selling drugs and now declines all medications. He did not complete high school, has a history of delinquency and attention problems, and currently works intermittently in construction. The maternal grandparents both have well‐controlled hypertension and hypercholesterolemia. The paternal grandparents’ histories are unknown to the father since he has not had contact with them in 15 years. Jason’s sister is healthy and doing average schoolwork.
Social history: Jason’s mom is single and lives on the second floor of a 1940s 2‐family house with the maternal grandparents on the first floor. Jason’s household consists of his mother, an 8‐year‐old sister, 2 dogs, and several cats. His mother and the children have frequent contact with the father, but he is not a regular part of the household. Both parents smoke while with the children. Jason attended day care full‐time until school entry but now returns home to the care of his grandparents after school. Toward the end of his time in day care, his mom reports that she had received a few calls about Jason’s behavior, specifically some difficulties participating in group activities and following directions.
Medications: Takes no medications.
OBJECTIVE
General: Alert, active, responsive to most requests with good articulation, some fidgeting with instruments.
Vital signs: Height: 46 inches (115 cm); weight: 45 lbs (20.9 kg); heart rate: 92; respiratory rate: 18; blood pressure: 98/62.
HEENT: Normocephalic; PERRL full EOMs, normal convergence, normal discs; gray TMs with good light reflexes and landmarks. Nose is normal, midline septum, boggy turbinates. Throat reveals large tonsils, no erythema, and uvula midline.
Neck: Supple; full range of motion; thyroid not palpable; no lymphadenopathy.
Cardiac: Regular rate and rhythm; S1/S2; no murmur; pulses full and equal.
Respiratory: Clear breath sounds throughout.
Abdomen: Soft, no mass, no hepatosplenomegaly.
Genitourinary: Normal male, circumcised, testes descended ×2.
Musculoskeletal: Full range of motion for all extremities; symmetric movement.
Neurologic: Normal tone, strength, coordination, reflexes and cranial nerves II‐XII grossly intact.
Skin: Clear, dry patches on elbows and knees.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___CBC___Thyroid studies___Lead screening___Vision screening___Hearing screening___Vanderbilt ADHD screening for school and parent___Learning disability evaluation___Pediatric Symptom Checklist
2 What is the most likely differential diagnosis and why?___Normal active behavior of early childhood___Hearing impairment___Attention‐deficit hyperactive disorder (ADHD)___Learning disability___Oppositional defiant disorder (ODD)___Conduct disorder___Depression
3 What is the plan of treatment?
4 What is the plan for follow‐up care?
5 Are there any demographic factors that might affect this case?
NOTE: The author would like to acknowledge Patricia Ryan‐Krause, MSN, APRN, who co‐authored this case in the first edition of this book.
Case 4.6 Cough and Difficulty Breathing
By Nancy Cantey Banasiak, DNP, PPCNP‐BC, APRN
SUBJECTIVE
Emily is a 6‐year‐old female who presents to the clinic with her mother. She presents with complaints of cough and difficulty breathing. Two days prior, Emily developed a nonproductive cough that is worse at night, clear rhinorrhea, and a fever with a maximum temperature of 102°F. The mother has treated the fever with Tylenol 320 mg every 4 hours, as needed, when the temperature was greater than 101°F. Her mother also complains that “when she gets a cold, it lasts longer than normal.”
Birth history: Emily was born full term weighing 3200 g by normal spontaneous vaginal delivery (NSVD). Pregnancy and delivery were uncomplicated with Apgar scores of 8 (1 minute) and 9 (5 minutes).
Social history: Emily is a 6‐year‐old female in the first grade who lives with her mom, dad, and 2 siblings in a house in the city. They have 4 pets: 2 dogs, 1 cat, and 1 turtle. The parents work outside the home and have private health insurance. Emily and her siblings attend an after‐school program until her mom picks them up after work. Emily attends regular medical and dental appointments, and they deny tobacco or alcohol use in the home. She plays soccer, ice hockey, and lacrosse.
Diet: Emily’s appetite is fair with a fluid intake of 32 oz/day of juice/milk/water. She also reports normal eating habits without abdominal pain or diarrhea.
Elimination: Emily voided 4 times yesterday. No vomiting or diarrhea. Her mother complains that everyone in the house is sick with the same symptoms.
Sleep: Emily sleeps from 8 p.m. to 6 a.m. She coughs 1–2 times during the night.
Past medical history: Past medical history is positive for obstructive sleep apnea 4. Birth history was uneventful. Emily also has a history of bronchiolitis at 8 months of age, which did not require medication or hospitalization.
Family history: Mother (age 36): healthy, atopic dermatitis, seasonal allergies; father (age 35): healthy, asthma, seasonal allergies; sibling (age 4): healthy; sibling (age 2): healthy; maternal grandmother (age 80): hypertension, breast cancer, basal cell skin cancer; maternal grandfather (age 81): hypertension, diabetes mellitus Type 2; paternal grandmother (age 76): hypertension, obesity; paternal grandfather (age 72): deceased, hypertension, stroke.
Medications: Emily is currently on no medications. Immunizations are up to date.
Allergies: Has no known allergies to medications, food, or the environment.