QUESTIONS THAT NEED TO BE ANSWRED FROM

QUESTIONS THAT NEED TO BE ANSWRED FROM CASE STUDY What is your list of appropriate differential diagnoses and why? What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings. Describe the pathophysiology that may lead up to the final diagnoses. What pharmacology treatment would you recommend and why? CASE STUDY INFO Your general pediatrics preceptor, Dr. Harris, asks you to start reviewing the chart on your next patient, Benjamin, who is here for his 3-year-old well-child visit. You hear several loud “No!”‘s coming from the exam room. The nurse comes out and gives you the chart, stating: “I wasn’t able to get his height and weight because he wouldn’t cooperate. I tried to test his vision, and didn’t have any luck with that either.” Fortunately, Dr. Harris earlier had advised you that sometimes you have to think like a preschooler when examining them, and you came prepared: You brought a handful of little cars and a bird that chirps. You quickly scan through Benjamin’s electronic health record: 18-month Visit New to practice Growth measures Height: 50th percentile Weight: 20th percentile Head circumference: 40th percentile Development Runs stiffly Speaks in two-word phrases Uses a spoon and cup Family History Mother had postpartum depression. Social History Grandma living with family. Father deceased in car crash. Lives in apartment complex built in 2002. Discussed Breath-holding Temper tantrums Age-appropriate behaviors Immunizations Reviewed vaccine record and patient is up to date including 15-month vaccines Hepatitis A vaccine given Screening Screening tools for development and autism (using the M-CHAT): Passed TB: No risk factors identified by questionnaire Lead: Screening questionnaire did not reveal any risk factors. Prior pediatrician documented normal hemoglobin and serum lead levels at 12 months of age. Labs Hemoglobin 11 g/dL 2-year Visit Growth measures Height: 50th percentile Weight: 25th percentile BMI: 28th percentile Concerns Rash Interval history “Nursemaid’s” elbow (radial head subluxation) reduced in the local emergency room. Development Two- to three-word sentences Can kick a ball Imitates adults Medical history Several colds Diet Picky Still using bottle at night Discussed Toilet training Starting daycare Grandmother will be leaving Stopping bottle Immunizations Influenza vaccine given Screening Developmental screening with Ages and Stages: Passed M-CHAT: Passed TB: No risk factors identified by questionnaire Serum Lead: 1 microgram per deciliter (< 5 mcg/dL is considered normal) Labs Hemoglobin 11.5 g/dL 30-month Visit Growth measures Height: 50th percentile Weight: 25th percentile BMI: 15th percentile Concern Difficulty going to sleep Temperament Unchanged: still having tantrums. Bedtime battles and waking at night since grandmother left. Screening Developmental screening with Ages and Stages: Passed Plan Age-appropriate behaviors related to sleep and tantrums discussed. Difficulties potentially linked to MGM departure. Mother should use consistent approach, weaning off her presence in Benjamin's room at night. Plan to observe for now. Follow-up call - 1 month: Mom initially had difficulty letting him sleep by himself, but now mom and Benjamin sleeping well. Mrs. Jones says, "See, look at this rash. I have put moisturizing cream on it almost every day - and over-the-counter hydrocortisone 1% cream for the past couple of weeks, but he keeps scratching at it, especially at night." (Minor parts of the exam like this often occur during the early part of the visit, especially if the parent has a key concern.) THE RASH IS ATOPIC DERMATITIS (EZCEMA) Eczema (Atopic Dermatitis) Eczema has been called "the itch that rashes," because there is a cycle of irritation leading to scratching, leading to the rash. Educate parents that anything leading to itching (even a child's rubbing his face on Mom's sweater) can exacerbate eczema. Eczema and Allergies Although eczema often occurs without a history of allergies, such a history would support an atopic diathesis and should prompt you to ask additional questions about allergic triggers and asthma symptoms. Family History While eczema tends to be familial, there is typically a multifactorial inheritance pattern and often clear environmental (allergic) triggers. Differential Diagnosis Sometimes eczema may be confused with the other common inflammatory rashes: Contact Dermatitis: This is very common in children and can be the result of any irritants including new products that they are using or something they came in contact with while playing. Scabies: This is an infection from mites that presents with a non-specific rash that is extremely itchy. Multiple family members may have similar rashes. Psoriasis: Although psoriasis can occasionally first look like eczema, it is rare in young children. When present, it occurs as a generalized rash known as guttate (droplet-shaped) psoriasis. Guttate psoriasis is usually precipitated by a strep infection. Seborrhea: This should also be part of the differential diagnosis, especially in early infancy (e.g., cradle cap). It is unusual to have a new case of seborrheic dermatitis at age 3. Treatment The basic tenets of the treatment of eczema are: Protecting skin by performing frequent daily moisturizing Using topical anti-inflammatories in short bursts Treating associated skin infections aggressively Pharmacological Treatment In developing an effective treatment plan, it is important to understand what treatment has been used already and with what results. Topical steroids Prescribe topical steroid, alternating a higher potency for severe flares with a lower potency for minor bouts. Often over-the-counter hydrocortisone is inadequate. Topical calcineurin inhibitors Calcineurin inhibitors are considered second-line therapy. Although effective, safety concerns remain for long term use. Antihistamines Remember that sometimes simply prescribing antihistamines can help with the itch, which in turn can prevent scratching and worsening of the rash. The non-sedating antihistamines approved for children - loratadine, fexofenadine, and cetirizine - may be effective. Traditional antihistamines (with sedative side effects) such as diphenhydramine and hydroxyzine are often used at bedtime to decrease itch. "At Benjamin's last visit, he seemed to be a picky eater. How has his eating been going lately?" "I'm glad you asked. We barely sit down to eat before he jumps up and is ready to play. He nibbles all day. He does eat a good breakfast but not much after that. He eats some cheese and fruit, but if Benjamin could have his way, he would only eat noodles - and milk. He drinks about four cups of milk a day. At dinner, he gets dessert only if he eats his meal. But then he ends up having a temper tantrum because he can't have dessert! "Last year Dr. Harris recommended we stop the bottle. We had gotten rid of it, but then Benjamin got sick and I let him have it again. He is still using it for naps and bed. He now drinks juice from a cup with a spout. He carries it around with him most of the day." Physical Exam of the Toddler and Preschooler General Tips Listen with your stethoscope first in case he/she starts crying. If the exam needs to be truncated due to the child's behavior, then you should focus on: Neurodevelopment Monitoring previously recognized findings New findings identified by parents, and Physical problems common in preschoolers for which intervention may be helpful Exam Area Possible Findings General Appearance Look for any dysmorphisms Assess whether well or ill-appearing HEENT Mouth: Caries Ears: Middle ear effusions that may persist after earlier URI and affect hearing. Click here to link to video demonstrating proper otoscope technique (with a notably cooperative patient): https://www.youtube.com/watch?v=b80LyZRZOFY&sns=em Eyes Strabismus (Discussed further below) Neck An enlarged thyroid is rare in children. Many children have "shotty" nodes (pea or marble-sized, nontender, easily mobile lymph nodes that are not fixed to surrounding structures) in the anterior and occasionally posterior cervical chain. These are normal in the cervical and inguinal chains in children and may persist for years. Cardiac Most murmurs will be functional. New murmurs of congenital heart disease are unlikely, but signs of atrial septal defect sometimes are appreciated better in older children. Lungs Yield likely to be low in a healthy child. May hear subtle wheezing in a child with a history of allergies or asthma. Abdomen Palpation for organomegaly and masses is appropriate. While the most common mass will be stool, children this age occasionally have an enlarged kidney or, very rarely, an abdominal tumor such as Wilms' or neuroblastoma. Skin Observe for rash, nevi, cafe-au-lait spots, birthmarks, or bruising Musculoskeletal Several gait variants occur at this age. The most common is intoeing. Intoeing in toddlers is usually caused by tibial torsion. In tibial torsion, when the patella faces straight ahead, the foot turns inward. Tibial torsion resolves naturally with weight bearing - usually by 4 years of age. Intoeing in preschool- and school-aged children is usually caused by femoral anteversion. In femoral anteversion both the feet and knees turn inward. Femoral anteversion usually resolves spontaneously by 8 to 12 years of age. Link to more information about intoeing: http://www.massgeneral.org/ortho-childrens/conditions-treatments/intoeing.aspx Genitals Hernias are sometimes seen. This segment of the exam also provides the opportunity to teach about who can appropriately examine the child. Some girls show nonspecific vulvar erythema due to poor hygiene once they are toilet trained and caring for themselves in the bathroom. Neurologic Assessment of overall muscle tone, strength, and coordination is appropriate. In general, the neuro exam at this age is more focused on assessing a child's achievement of overall neurodevelopmental status, including gross and fine motor, along with language and social-skills milestones. TEACHING POINT PHYSICAL EXAM At this point, Benjamin is comfortable enough to cooperate with measurements and vital signs: Weight is 13.4 kg (29.5 lbs) (25th percentile) Height is 95 cm (37.4 in) (50th percentile) BMI is 14.8 (10th percentile) Temperature is 36 Celsius (96.8 F) Pulse 110 beats/minute Respiratory rate is 22 breaths/minute Blood pressure is 80/50 mmHg You continue with the least invasive and engaging activities of the physical exam. You listen to his heart and lungs first, followed by his abdominal and GU exam, concluding with the HEENT exam. General appearance: Well appearing, no dysmorphic features. Head, eyes, ears, nose and throat (HEENT): Normocephalic. Red reflex positive bilaterally. Extraocular movements intact. No strabismus noted with cover/uncover test. Normal nares. Tympanic membranes pearly, no retraction. Moist mucous membranes. Visible dental caries. Neck: No masses or lymphadenopathy. Cardiac: Normal S1, S2; regular rate and rhythm; no murmur. Femoral pulses equal bilaterally. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nondistended, nontender. No palpable masses. GU: Circumcised. Both testes palpated. Skin: Mildly erythematous excoriated patches on anterior trunk and antecubital fossae. Other than dental caries and eczema, no significant findings. Benjamin enjoys sharing your "tools" with you during your exam. He particularly likes the notion of "looking for elephants" in his ears. You remember that Dr. Harris wants you to review safety issues and try to provide families with guidance. SCREENING LAB TESTS Capillary hemoglobin: 9.5 g/dL (100 g/L) Normal range between 6 months old and 6 years old: 10.5-14 g/dL (105-140 g/L) You and Dr. Harris return to the examining room and explain to Mrs. Jones that Benjamin's current eating patterns have resulted in a mild anemia and have also put him at risk for developing cavities. "Besides treating his anemia with iron, we want to improve his eating to prevent any further problems." You review with her the four suggestions from the previous page. Dr. Harris warns her, "We expect Benjamin to initially object a lot, but then become used to the new rules. You know, it is OK to be more stubborn than he is, even if he has a tantrum! You also discuss the benefit of fluoride varnish to help decrease his risk of dental caries. Mrs. Jones agrees to have the varnish applied to Benjamin's teeth today in clinic. Dr. Harris schedules a recheck of the anemia, eating behaviors, and eczema in six weeks, and tells Mrs. Jones to let him know if she has trouble getting him to take his iron. Dr. Harris advises Mrs. Jones that the iron supplement may cause dark stool and/or constipation but that these are normal side effects of the iron. He encourages her to schedule a visit for Benjamin with the dentist to address his cavities. Dr. Harris tells her that the prescriptions for iron and for hydrocortisone 2.5% ointment have been submitted to her pharmacy. SCIENCE HEALTH SCIENCE NURSING NURSING NSG 6023

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