Pediatric Primary Care Case Studies (2 page)

Chapter 31

The Teen Boy with Acne
   
Catherine E. Burns
   Danielle J. Poulin

Chapter 32

The Limping Child
   
Jan Bazner-Chandler

Chapter 33

The Late-Preterm Baby Beginning Well-Child Care
   
Lori J. Silao

Chapter 34

A Child with Short Stature
   
George Anadiotis

Index

Preface

Pediatric Primary Care Case Studies
was written by nurse practitioner, physician, and physician assistant clinicians and educators who believe that health care for children in primary care settings should be excellent, whatever the discipline of the provider. This book is designed to exemplify the critical thinking process and diagnostic reasoning skills that clinicians should use to assess and manage treatment of the infants, young children, and adolescents who present with common signs and symptoms of childhood illnesses or behavioral problems in providers’ practice settings.

These cases were developed to reflect common pediatric healthcare problems such as depression, obesity, autism, attention-deficit hyperactivity disorder, and environmental health concerns among many others. The chapter authors address key elements in the reasoning process that should be employed as the provider gathers data about a case from the initial presentation through the diagnostic decision and highlight the standards of treatment for the selected diagnosis. Additionally, the cases discuss concerns surrounding children from a variety of socioeconomic, cultural, familial, and developmental backgrounds.

We hope this book helps fill in gaps in the clinical knowledge of students who have completed didactic courses and guides their preparation for clinical work by taking an organized approach to symptom-driven presentations.

Organization of the Book

This book is divided into three sections, which follow an introductory chapter reviewing essential features of the diagnostic approach to pediatric primary care. Unit I covers developmental problems in children from infancy through adolescence—motor delays, language delays, learning problems in school, and sleeping too much. The cases in Unit II involve functional health problems, beginning with a case study illustrating principles of health maintenance. Subsequent cases include an obese child with unhealthy nutritional practices, a breastfeeding infant who is not gaining weight, a constipated child, a child needing a preparticipation sports examination, an infant not sleeping through the night, a child with attention and hyperactivity issues, a child who is abused, a child with possible depression, and a teen who thinks she might be gay. Finally, Unit III surveys common medical symptoms and related conditions which the provider will see and should not miss—wheezing, type 2 diabetes, anemia, headache, a red eye, recurrent ear infections, a heart murmur, cough, vomiting and diarrhea, dental trauma, urinary tract infection, a birth control request, sexually transmitted infection, an itchy rash, acne, a limp, preterm infant care, and a possible genetic syndrome.

This book was designed to demonstrate how a healthcare provider should incorporate the concepts of critical thinking into a practical model of diagnostic reasoning that he or she would use daily. Scenarios are presented with information emerging chronologically. The author for each case becomes the expert guiding the reader in the decision-making process, thinking through the case as it progresses. Additional elements such as familial, developmental, and cultural issues are intertwined in the case presentations to illustrate how they are factored into the assessment and decision-making process.

Generally, as in real practice, the child and family member(s) present with a “chief complaint.” From there the experts begin to reason their way through the assessment process, considering some diagnoses and reflecting as they go along on the data they have collected and what they know about the etiology and pathophysiology associated with various symptoms. A Making the Diagnosis section follows some discussion of various diagnoses already considered and discarded during the assessment process. The Management section sometimes involves several visits, with additional information coming in at each visit related to confirmation of the diagnosis, initial management, long-term management, and confirmation of problem resolution. The references used reflect the “best practice” information the expert is using for decisionmaking, but are by no means an exhaustive review of the literature. Tables are sometimes used to display information in an easily viewed style.

Cases are initially described in terms of the symptom because that is where the clinician must begin. A symptom analysis occurs early in the presentation of each case. From there, various diagnoses are considered and either supported or refuted with further data. Of course, some diagnoses, such as acne, are predominantly self-evident whereas others, such as a syncope episode, require greater analysis before a diagnosis can be determined.

About the Authors and Contributors

The contributors for this text were selected for their expertise and experience in caring for infants, children, and adolescents. They represent a variety of specialties and are from all parts of the United States and Canada. Each of the lead authors has more than 20 years of experience practicing and teaching pediatric primary care to a variety of students in nurse practitioner and medical fields. Dr. Richardson has authored a text on pediatric physical assessment that is widely used, as well as a book of pediatric practice guidelines. The idea for this book is hers and she should be credited with its creation. Drs. Burns and Brady are coauthors on the widely used
Pediatric Primary Care
text (Elsevier, 2009), which is now in its fourth edition and used by many pediatric and family nurse practitioner programs.

We hope this book will meet a current educational need of all pediatric primary care provider students and their educators and preceptors as well as less experienced clinicians in practice.

Contributors

George Anadiotis, DO

Pediatric Development & Rehabilitation Services

Legacy Emanuel Hospital for Children

Portland, Oregon

Jan Bazner-Chandler, MSN, CNS, CPNP

Assistant Professor

Azusa Pacific University

Azusa, California

Catherine G. Blosser, MPA-HA, PNP-BC, RN

Pediatric Nurse Practitioner (Retired)

Multnomah County Health Department

Oak Grove, Oregon

Deborah A. Bohan, MEd, PA-C

Physician Assistant

Department of Pediatrics

Allegheny General Hospital

Pittsburgh, Pennsylvania

Kathleen M. Boyd, MD

Assistant Professor of Pediatrics

Indiana University School of Medicine

Indianapolis, Indiana

Ardys M. Dunn, PhD, PNP, RN

Associate Professor Emeritus

School of Nursing

University of Portland

Portland, Oregon

Professor (Retired)

Samuel Merritt College School of Nursing

Oakland, California

Prashant Gagneja, DDS, MS

Chairman, Pediatric Dentistry

School of Dentistry

Oregon Health & Science University

Portland, Oregon

Dawn Lee Garzon, PhD, CPNP

Assistant Professor

University of Missouri–St. Louis

St. Louis, Missouri

Teral Gerlt, MS, PNP, RN-C, WHCNP

Instructor

School of Nursing

Oregon Health and Sciences University

Portland, Oregon

Ann M. Guthery, PhD(c), PMHNP, RN

Clinical Assistant Professor

College of Nursing

Arizona State University

Phoenix, Arizona

Anna Marie Hefner, MSN, MAEd, RN, CPNP

Associate Professor

School of Nursing

Azusa Pacific University

Azusa, California

Pamela J. Hellings, PhD, RN, CPNP-R

Professor Emeritus

Oregon Health and Science University

Portland, Oregon

Lynne Henry, MSN, RN, CPNP

St. Vincent Health Network

North Vernon, Indiana

Ritamarie John, DNP, CPNP-PC

Program Director

Assistant Professor of Pediatrics

Columbia University

School of Nursing

New York, New York

Elissa Jones-Hua, MSN, RN, CPNP

Nurse Practitioner

Developmental Pediatrics

Riley Hospital for Children

Indiana University

Indianapolis, Indiana

Veronica Kane, PhD, CPNP

Pediatric Specialty Coordinator

Clinical Assistant Professor

MGH Institute of Health Professions

Boston, Massachusetts

Tamra D. Kehoe, MSN, RN, CPNP

Pediatric Nurse Practitioner

Multnomah County Health Department

Portland, Oregon

Donald W. Kennerly, MD, CCFP

Belleville General Hospital

Belleville, Ontario, Canada

Patrick E. Killeen, MS, PA-C

Department of Pediatrics

Danbury Hospital

Danbury, Connecticut

Shelly J. King, MSN, RN, CPNP

Director Children’s Continence Center

Pediatric Urology, Riley Hospital for Children

Indiana University

Indianapolis, Indiana

Larry W. Lynn, MD

Assistant Professor

Physician Assistant Program

Butler University

Indianapolis, Indiana

Brian T. Maurer, MS, PA-C

Pediatric Physician Assistant

Enfield Pediatric Associates

Enfield, Connecticut

Ann Marie McCarthy, PhD, RN, FAAN

College of Nursing

University of Iowa

Iowa City, Iowa

Beth Moore, MSN, RN

Long Beach Memorial Medical Center

Miller Children’s Hospital

Long Beach, California

Jennifer Newcombe, MSN, CNS, CPNP

Loma Linda Children’s Hospital

Loma Linda, California

John Peterson, DDS

Professor (Part time)

Pediatric Dentistry

School of Dentistry

Oregon Health and Science University

Portland, Oregon

Danielle J. Poulin, MSN, PNP, RNC

Pediatric Nurse Practitioner

Western Medical Center–Santa Ana

Santa Ana, California

Michele Saysana, MD, FAAP

Clinical Assistant Professor of Pediatrics

Indiana University School of Medicine

Indianapolis, Indiana

Lori J. Silao, MN, RN, CNNP

Adjunct Faculty

Azusa Pacific University

Azusa, California

Sheran M. Simo, MSN, FNP-BC

Nurse Practitioner

St. Vincent Primary Care Network

Indianapolis, Indiana

Arlene Smaldone, DNSc, CPNP, CDE

Assistant Professor

Columbia University

School of Nursing

New York, New York

Deborah Stiffler, PhD, RN, CNM

Assistant Professor

Coordinator, Women’s Health Nurse Practitioner Major

Indiana University

School of Nursing

Indianapolis, Indiana

Victoria Winter, MSN, PNP, RN

Adjunct Professor

Azusa Pacific University

Pediatric Nurse Practitioner Program

Azusa, California

Cardiothoracic Intensive Care

Children’s Hospital Los Angeles

Los Angeles, California

Sharon Yearous, PhD, RN, CPNP, NCSN

Executive Director

Iowa School Nurse Association

Cedar Rapids, Iowa

Chapter 1

Diagnostic Reasoning:
A Complex Issue for
Pediatric Primary Care

Catherine E. Burns

Pediatric primary care providers use a critical thinking skill set to help them arrive at a diagnosis and to provide efficient, cost-effective care to their patients. Evidence-based practice has become a guiding principle that is consistent with the diagnostic reasoning process: using the best information available as one thinks through the pros and cons of various pathways that emerge along the road from diagnosis to management and problem resolution.

The clinician is typically taught to move from assessment to diagnosis to intervention and, finally, to evaluation in a linear fashion; however, in reality, the practicing clinician considers various diagnoses while conducting the assessment so that data will confirm or refute various possible diagnoses. Sometimes, management strategies also have diagnostic elements—if the plan doesn’t work, then perhaps the diagnosis was wrong. For example, if iron supplementation does not result in raising a low hemoglobin level and further tests were not done initially, then perhaps the problem was not iron-deficiency anemia. Therefore, additional tests must be done to identify another diagnosis. Thus, the use of iron supplementation had diagnostic elements. The problem-solving or diagnostic reasoning process may be linear (i.e., diagnosis generally comes before intervention), but during a given episode the process generally is more convoluted than linear. The clinician also must think on his or her feet with only minimal time for reflection. Delivering primary care to pediatric patients often presents unique diagnostic challenges for healthcare providers.