Skin: Color is appropriate for race; no pallor. No rashes or hives noted. Patch of mild eczema on left lower extremity. Temperature and texture otherwise within normal limits.
CRITICAL THINKING
1 What are the top three differential diagnoses? What testing will confirm the diagnosis?
2 How should the provider educate the mother about the seriousness of anaphylaxis and the risk of it occurring again?
3 How can the provider help the school manage a child with food allergies?
4 If this family does not have insurance, what is the expected out‐of‐pocket expense for an EpiPen? Likely more than one will be needed, so how can a family navigate this barrier?
5 What is the essential information that all caregivers (not just parents) need to know when caring for James?
6 What advice should the mother be given regarding introduction of peanut‐based products to the youngest child now that food allergies are known to be in the family?
Case 4.11 Obesity
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Tamika, a 12‐year‐old girl, came to the community health clinic with her mother, who had requested an urgent appointment to discuss a note from Tamika’s physical education teacher with her nurse practitioner (NP). The note stated that Tamika was having difficulty keeping up with her classmates because she became short of breath when participating in activities. Tamika denies any other episodes of shortness of breath but reports that she occasionally has to stop and rest when climbing stairs. She has no persistent cough, wheeze, or seasonal allergies. She reports that she has not yet had a period.
Diet history: Tamika seldom eats breakfast at home and occasionally will eat cereal from the school breakfast. For lunch she likes pizza or macaroni and cheese but does not eat if these items are not on the school menu. She arrives at her grandmother’s house around 3:30 p.m. and has a salty snack and a soda. She eats dinner with her father, either at home or at a local fast‐food restaurant.
Sleep history: Tamika’s mother notes that she snores loudly and sometimes awakens at night. She is currently not taking any medications.
Past medical history: Tamika was born after 36 weeks’ gestation to a 39‐year‐old mother. She weighed 4 lb 14 oz; and, in addition to being preterm, she was small for gestational age. Her mother smoked ½ ppd. Her neonatal history was unremarkable, and she was discharged at 1 week of age weighing 5 lb 2 oz. She was formula fed.
Her past medical history is otherwise unremarkable except for treatment on 2 occasions for right otitis media at ages 1 and 5 and for day surgery at age 18 months to repair a bilateral inguinal hernia. There were no complications. She has no history of respiratory illness, asthma, or allergy.
Family history: Positive for Type 2 diabetes in Tamika’s maternal grandmother. Her father is positive for cardiovascular disease and had a mild heart attack at age 48, has high blood pressure, and takes statins for elevated cholesterol. Her maternal grandfather died at age 42 from a heart attack and diabetes. Her paternal grandparents are reportedly alive and well and are living in Puerto Rico.
Social history: Tamika is in sixth grade. She is seldom absent and frequently makes the honor roll. She says she likes school but notes that she is shy and has few friends. She does not take part in any extracurricular activities and spends her after‐school time helping her grandmother cook or watching TV. She likes to read. She denies ever using tobacco products, drugs, or alcohol. She admits to feeling sad and lonely at times but denies ever wanting to injure herself. She likes her parents but says they don’t always understand her or have time to talk to her.
Tamika lives with both parents in a 2‐bedroom, third‐floor apartment near her school. Her father is employed as a laborer, and her mother works for a cleaning service 5 evenings a week. The family has a stable income. Tamika has 3 older siblings, ages 17, 19, and 21, living outside of the home. Her maternal grandmother lives nearby, and Tamika often goes to her home after school. Both parents were smokers previously but stopped 5 years ago. They moved to this area from Puerto Rico 20 years ago. Both speak fluent English.
OBJECTIVE
General: Tamika is a 12‐year‐old, Hispanic female who is neatly dressed and cooperative.
Vital signs: She is 5 feet tall and weighs 174 pounds. Her blood pressure is 116/70, pulse is 74, and respirations are 16 breaths/minute. Temperature is normal.
HEENT: PERRLA; EOMs intact. Oral pharynx is positive for 3+/4 tonsils, without lesions or exudate. No dental caries are noted.
Neck: Supple with full range of motion. No lymphadenopathy is present.
Respiratory: Her lungs are clear bilaterally with no wheezes, rales, or rhonchi.
Cardiac: Normal sinus rhythm with no murmur or irregular beats.
Chest: Breast buds are present bilaterally, with no tenderness or discharge.
Abdomen: Soft but protuberant with no masses or hepatosplenomegaly. Normal bowel sounds are heard in all 4 quadrants.
Neuromuscular: Back is straight with no curvature noted on forward bend. She has full range of motion in all extremities. Reflexes are normal.
Skin: Clear except for darkly pigmented areas on her neck.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___BMI___Oral glucose tolerance test (OGGT)___Insulin resistance___Cholesterol screen___Sleep study___Psychosocial evaluation
2 What is the most likely differential diagnosis and why?___Sleep apnea___Obesity___Insulin resistance___Type 2 diabetes___Exercise intolerance___Psychosocial issues
3 Are any referrals needed at this time?
4 Can the school be of assistance?
5 What community resources are available to this family?
6 What type of nutrition support may aid this family?
NOTE: The author would like to acknowledge Elaine Gustafson, MSN, PNP, who co‐authored this case in the first edition of this book.
Case 5.1 Drug Use
By Anna Goddard, PhD, APRN, CPNP‐PC
SUBJECTIVE
Natalie is a 17 year‐old female who presents to the school‐based health center (SBHC) for the fourth time in 1 week with nonspecific complaints. Several teachers have reported Natalie falling asleep in class and “thinks she might be on drugs.” Her grades have continued to decrease this semester from C averages to barely passing most of her classes. Natalie reports she is tired “all the time” even though she claims to sleep 8–10 hours a night. She reports frequently waking up and not being able to fall back asleep. She does not like school and states “I don’t need anything I am learning in school.” When offered the PHQ2 and CRAFFT to complete as part of routine screening, she refused to complete both of them. She is requesting to be sent home.
Past medical history: