Andrew Presentation at a Primary Health Care Clinic Case Study

Assignment Task

Case Study Assignment 

The purpose of the case assignments is to apply knowledge and theory to a case study, focusing on content already covered in the program.

Case study

Andrew, an 8-month-old male presents to a rural primary health care clinic. Over the past three days, Andrew has become increasingly irritable, has vomited multiple times each day, and is frequently rubbing at his right ear. His mother states that a mild cold is going through the house and is concerned because Andrew refused his bottle today. Andrew was transitioned from breast milk at 6-months of age to homogenized milk. Andrew is exclusively given homogenized milk through a bottle. His mother says that he has 6-8 wet diapers each day and has a bowel movement every 3-4 days. She says that Andrew seems to have difficulty passing stool, straining, and grunting. Andrew’s mother denies seeing blood in his stool, diaper, or on the wipes.

Birth History: Term infant born at 40 +2 days gestation. Vaginal delivery without complications. No complications during pregnancy.

Hospitalizations: None

Past Medical History: Unremarkable

Immunizations: Up to date

Medications: Tylenol as needed

Allergies: NKA

Family history: Mother: mild asthma. Father healthy. No siblings.

Social history: Lives with mother and father. Both parents farm, but mother is presenting focusing on raising Andrew. Both parents smoke cigarettes, but only smoke outside. The family has numerous pets: two dogs, three cats, and a rabbit.

Development: Babbling, rolling (front to back and back to front), and sitting unsupported. Can stand with support for short periods. Lethargy, not as active as earlier.

On Exam

General appearance: Andrew appears pale, is crying and irritable, clinging to mom. No cyanosis. No increased WOB.

Vitals: Axillary Temperature 36.2°C. HR 145 beats/min. RR 42 breaths/min. SpO2 99% RA.

Weight 9.8 kg Height: 68.3 cm Head Circumference: 45 cm

HEENT: Sclera white; no discharge. Right TM is mildly reddened, transparent, flat, no perforation, no exudate. Left TM is pearly gray, translucent, flat, no perforation, no exudate. Mild clear nasal secretions. Oral mucosa pink and moist.

Neck: No lymphadenopathy.

Resp: No accessory muscle use. Chest clear and air entry equal BL. No adventitious sounds. CVS: S1 S2. No S3. No S4. No murmur.

Abdo: BS x 4. No bruits. Soft, non-tender, but mildly distended. No palpable masses. No organomegaly.

Neuro: Screening exam normal, besides that Andrew is fussy.

Question

1. Applying data and findings from the case, identify the chief concern.

2. Based on the case history, what areas of concern would you explore in your initial assessment and why? Identify any red flags or areas of high risk. Be specific and link your answer(s) to the patient information and provide supporting rationale.

3. Identify five (5) diagnostic tests you might include in your initial assessment of this client. Provide supporting rationale for the selection. If you believe that diagnostic tests are not warranted, provide supporting rationale.

4. Identify and rank the three (3) most likely differential diagnoses including rationale/reasoning. Rank the differentials with rule-in and rule-out table. This must be included in the body of the paper.

5. Identify an initial treatment plan for this client (i.e., education, pharmacological management, nonpharmacological management, referrals). Include supporting rationale. If your plan includes pharmacological management, you must provide a detailed written prescription and include it as an appendix (as per APA), so the prescription does not count towards the page limit. You do not need to add your signature, just your name. You can make up the patient demographics and clinic information.

6. Provide a brief case summary of the clinical scenario. 

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