Case Study 1:
HPI: A mother presents with her 2-year-old African American male child with complaints of ear pain and decreased sleep. Earlier this week, he had a runny nose and congestion with a mild cough that occurred mostly when lying down. His temperature is 100.7.
PE: Pt is walking around room, exploring in no acute distress.
HEENT: Mild nasal congestion, clear postnasal drainage, and lungs clear to auscultation. Ear exam reveals right tympanic membrane erythematous, translucent, in a neutral position, with no pus or fluid noted. Left tympanic membrane is full, reddish/orange in appearance, and opaque with pus.
Neck: Shotty anterior cervical adenopathy
Lungs: Clear to auscultation
• Review “Eye Disorders” and “Ear Disorders” in the Burns et al. text.
• Review the three case studies focusing on the case that is assigned to you. Analyze the patient information, including the parent’s perspective.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating parents on the child’s disorder and reducing any concerns/fears presented in the case study.
By Day 3
Post an analysis of your assigned case by responding to the following:
o What additional questions will you ask?
Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
o What additional examinations or diagnostic tests, if any will you conduct?
o What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
o What is your most likely diagnosis and why?
o How will you treat this child?
Provide medication treatment and symptomatic care.
Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
o Patient Education, Health Promotion & Anticipatory guidance:
Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
Include any socio-cultural barriers that might impact the treatment and management plans.
What immunizations should this child have had?
Based on the child’s age, when is the next well visit?
At the next well visit, what are the next set of immunizations?
What additional anticipatory guidance should be provided today?
Case Study 1: