Medications: Daily multivitamin.
Allergies: Amoxicillin (hives, at age 2)
OBJECTIVE
Vital signs: Weight: 140 lbs; height: 68 inches; BMI: 21.3; temperature: 100.4°F; HR: 76; RR: 16; B/P: 108/72.
General: Alert, tired appearing but in no acute distress.
HEENT: Head is normocephalic and atraumatic. Scleras are clear. PERRLA bilaterally. Normal fundi exam bilaterally. Otoscopic exam reveals normal tympanic membranes with visible landmarks and appropriate light reflex. Nares are patent. Oropharynx is normal without erythema or exudate. Tongue is midline.
Skin: No rashes noted on exam. Skin is warm and dry.
Neck: No lymphadenopathy present. Full range of motion with no reported pain.
Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi present.
Cardiovascular: Regular rate and rhythm. S1S2 normal. Pulses 2+ throughout.
Gastrointestinal: Abdomen soft, nontender, nondistended, with no masses or hepatosplenomegaly palpated. Bowel sounds normoactive in all 4 quadrants.
Neurological: Alert and oriented. Grossly normal. Sensation intact to lower extremities. Patellar and Achilles deep tendon reflexes 2+ bilaterally.
Musculoskeletal: Assessments of the joints, with a particular focus on those of his right lower extremity (hip and ankle) are normal with the exception of the right knee. Left lower extremity exam is normal, and there is obvious asymmetry between the two knees. To right lower extremity: minimal tenderness to the knee joint upon palpation. The knee feels warm to touch. Non‐pitting edema is present. Further exam displays a positive “bulge” sign, evidence of fluid collection in the joint, as well as a negative McMurray test and negative anterior drawer sign test/Lachman test. The patella tracks normally. Range of motion of the right knee is limited due to swelling, with full extension but flexion limited to only 90°. No hypermobility is noted. Full strength (5/5) is noted to right lower extremity, and Peter’s gait is normal with no limp at time of exam.
CRITICAL THINKING
1 Which diagnostic tests should be ordered in this case and why?___Complete blood count (CBC)___Comprehensive metabolic panel (CMP)___Erythrocyte sedimentation rate (ESR)___C‐reactive protein (CRP)___Rheumatoid factor___Anti‐nuclear antibody (ANA)___Lactic acid dehydrogenase (LDH)___Enzyme‐linked immunosorbent assay with reflex Western blot (ELISA)___X‐ray___Magnetic resonance imaging (MRI)___Synovial fluid (cell counts, Gram stain, culture and sensitivity, PCR)
2 What is the most likely differential diagnosis and why?___Infectious cause (septic arthritis, osteomyelitis, Lyme arthritis)___Autoimmune diseases (juvenile idiopathic arthritis, systemic lupus erythematous)___Trauma/Injury___Malignancy (tumor secondary to osteosarcoma, lymphoma, neuroblastoma)
3 What is the plan of treatment?
4 What are the plans for referral and follow‐up care?
5 What health education should be provided to this patient?
6 What demographic characteristics might affect this case?
7 Are there any standardized guidelines that should be used to treat this case? If so, what are they?
8 Is there any other information that would be helpful in determining a diagnosis?
9 If this patient were 6 years old, would it change how he would be tested and treated?
10 At what point would inpatient treatment be more appropriate than outpatient for this patient?
Case 6.1 Preconception Planning
By Sara Smoller, RN, MSN, ANP‐BC
SUBJECTIVE
Delilah is a 28‐year‐old female who presents to discuss her plans to conceive. She is in a monogamous relationship with her husband. They are excited about the possibility of starting a family and want to do so in 6 months when her husband gets out of law school. Delilah wants to know what she should be doing to ensure that she is healthy and has a healthy pregnancy. She is worried she may have difficulty getting pregnant as her older sister had to go through in‐vitro fertilization; she is wondering if she needs a referral to a fertility specialist. She has never been pregnant before. Her last Pap smear was 3 years ago and was normal. Her last menstrual period was 2 weeks ago. She reports regular menses.
Past medical history: G0P0; moderate persistent asthma, currently well controlled; appendectomy at age 21
Family history: Mother with Type 2 diabetes; father with bipolar depression (poorly managed)—she has minimal contact.
Social History: Delilah works as a flight attendant 7 days on, 7 days off. She engages in minimal physical activity other than being active/on her feet at work. She’s been married for 2.5 years and feels safe at home. Her husband is in law school. Delilah drinks 1–2 glasses of wine per night and smokes “socially” about 5 cigarettes per week. She denies any marijuana or other drug use. Her sleeping habits are poor; when she is working she is flying between time zones and often is awake overnight. She states she averages about 5 hours of sleep per night. She drinks 3–4 cups of black coffee daily.
Medications: Fluticasone inhaler 220mcg 1 puff bid; albuterol inhaler 1–2 puffs q6h prn shortness of breath; Apri OCPs; Ibuprofen 200–400 mg prn headache
Allergies: NKDA
OBJECTIVE
Vital signs: Temperature 97.6°F (orally); BP 118/72; pulse 72 and regular. She is 5 ft 5 inches tall and 183 pounds.
General: Delilah is pleasant and cooperative and is sitting comfortably in the exam room.
Eyes: PERRL. No injection or icterus.
Mouth: No lesions or exudates.
Neck: Thyroid palpable without enlargement or nodules.
Cardiac: Regular rate and rhythm, no murmurs.
Lungs: Clear bilaterally.
Breasts: No lumps, masses, nipple discharge, or skin changes.
Abdomen: Soft, nontender, nondistended. No palpable masses or hepatosplenomegaly.
CRITICAL THINKING
1 What health recommendations should be made for Delilah in order to help her prepare for pregnancy?
2 What laboratory/diagnostic testing is recommended?
3 How Delilah’s medication list be adjusted? Are any of the medications teratogenic? Are there any medications/vitamins or supplements she should start taking?
4 When should she stop her birth control pills?
5 How should she be counseled about seeing a fertility specialist? When would this be recommended?
6 Would anything be different if Delilah were 38 instead of 28?
7 Are any other referrals recommended?