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The Family Nurse Practitioner | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner Clinical Case Studies SECOND EDITION Edited by Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN Mansfield Kaseman Health Clinic Rockville, MD, USA | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
This edition first published 2021 © 2021 John Wiley & Sons Ltd Edition History John Wiley & Sons, Inc. (1e, 2011) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www. wiley. com/go/permissions. The right of Leslie Neal‐Boylan to be identified as the author of the editorial material in this work has been asserted in accordance with law. Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www. wiley. com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no represen-tations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging‐in‐Publication Data Names: Neal-Boylan, Leslie, editor. Title: The family nurse practitioner : clinical case studies / [edited by] Leslie Neal-Boylan. Other titles: Clinical case studies for the family nurse practitioner. | Case studies in nursing. Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2021. | Series: Case studies in nursing | Preceded by Clinical case studies for the family nurse practitioner / [edited by] Leslie Neal-Boylan. 2011. | Includes bibliographical refer ences and index. Identifiers: LCCN 2020026509 (print) | LCCN 2020026510 (ebook) | ISBN 97811 19603191 (paperback) | ISBN 9781119603214 (adobe pdf) | ISBN 97811 19603221 (epub) Subjects: MESH: Family Nurse Practitioners | Family Nursing | Primary Care Nursing | Case Reports Classification: LCC RT82. 8 (print) | LCC R T82. 8 (ebook) | NLM WY 128 | DDC 610. 7306/92-dc23 LC recor d available at https://lccn. loc. gov/2020026509 LC ebook record available at https://lccn. loc. gov/2020026510 Cover Design: Wiley Cover Image: © Arthur Tilley/Getty Images Set in 10/12pt Palatino LTStd by SPi Global, Pondicherry, India 10 9 8 7 6 5 4 3 2 1 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Contents Contributors xi Preface xv Acknowledgments xvii Intr oduction xix By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, FARN Abbreviations and Acronyms xxi Section 1 The Neonate 1 Case 1. 1 Cardiovascular Screening Exam 3 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 1. 2 Pulmonary Screening Exam 7 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 1. 3 Skin Screening Exam 11 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 1. 4 Oxygenation 15 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 1. 5 Nutrition and Weight 19 By Mikki Meadows-Oliver, Ph D, RN, F AAN Section 2 The Infant 23 Case 2. 1 Nutrition and Weight 25 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 2. 2 Breastfeeding 29 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 2. 3 Growth and Development 33 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 2. 4 Heart Murmur 37 By Mikki Meadows-Oliver, Ph D, RN, F AAN v | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
vi Contents Case 2. 5 Cough 41 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 2. 6 Diarrhea 45 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 2. 7 Fall from Height 49 By Mikki Meadows-Oliver, Ph D, RN, F AAN Section 3 The Toddler/Pr eschool Child 53 Case 3. 1 Earache 55 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 2 Bedwetting 57 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 3 Burn 61 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 4 Toothache 63 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 5 Abdominal Pain 67 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 6 Lesion on Penis 71 By Mikki Meadows-Oliver, Ph D, RN, F AAN Section 4 The School-Aged Child 75 Case 4. 1 Rash without Fever 77 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 2 Rash with Fever 79 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 3 Red Eye 83 By Andrew Konesky, MSN, APRN Case 4. 4 Sore Throat 85 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 5 Disruptive Behavior 89 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 6 Cough and Difficulty Breathing 93 By Nancy Cantey Banasiak, DNP, PPCNP-BC, APRN Case 4. 7 Left Arm Pain 95 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 8 Nightmares 97 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 9 Gastrointestinal Complaint 101 By Allison Grady, MSN, APNP | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Contents vii Case 4. 10 Food Allergies 103 By Allison Grady, MSN, APNP Case 4. 11 Obesity 107 By Mikki Meadows-Oliver, Ph D, RN, F AAN Section 5 The Adolescent 11 1 Case 5. 1 Drug Use 113 By Anna Goddard, Ph D, APRN, CPNP-PC Case 5. 2 Weight Loss 115 By Anna Goddard, Ph D, APRN, CPNP-PC Case 5. 3 Menstrual Cramps 119 By Vera Borkowski, MSN, APRN, FNP-C Case 5. 4 Missed Periods 121 By Vera Borkowski, MSN, APRN, FNP-C Case 5. 5 Birth Contr ol Decision-Making 123 By Jessica Chan, MSN, APRN, PPCNP-BC Case 5. 6 Vaginal Dischar ge 125 By Betsy Gaffney, MSN, APRN, FNP-BC Case 5. 7 Sexual Identity 127 By Betsy Gaffney, MSN, APRN, FNP-BC Case 5. 8 Knee Pain 129 By Jessica Chan, MSN, APRN, PPCNP-BC Section 6 Women' s Health 133 Case 6. 1 Preconception Planning 135 By Sara Smoller, RN, MSN, ANP-BC Case 6. 2 Bleeding in the First Trimester of Pregnancy 137 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 3 Night Sweats 139 By Ivy M. Alexander, Ph D, APRN, ANP-BC, F AANP, FAAN and Annette Jakubisin-Konicki, Ph D, ANP-BC, FNP-BC, FAANP Case 6. 4 Pelvic Pain 145 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 5 Vaginal Itching 147 By Sara Smoller, RN, MSN, ANP-BC Case 6. 6 Redness and Swelling in the Breast 149 By Karen M. Flaherty, MSN, MEd, APRN-BC, CBCN Case 6. 7 Sexual Assault 151 By Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Case 6. 8 Abdominal Pain 155 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
viii Contents Case 6. 9 Urinary Frequency 157 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 10 Headache 159 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 11 Fatigue and Joint Pain 161 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 12 Muscle Tenderness 165 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 6. 13 Insomnia 169 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Section 7 Men's Health 173 Case 7. 1 Fatigue 175 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 7. 2 Testicular Pain 179 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 7. 3 Prostate Changes 181 By Clara Gona, Ph D, FNP-BC, RN Section 8 General Adult Health 183 Case 8. 1 Substance Use Disorder (SUD) 185 By Jason R. Lucey, DNP, FNP-BC Case 8. 2 Foot Ulcer 187 By Susan M. Jussaume, MSN, APRN, FNP-BC, AHN-BC Case 8. 3 Abdominal Pain and Weight Gain 191 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 4 Burning Leg Pain 195 By Antonia Makosky, DNP, MPH, ANP-BC, ANP Case 8. 5 Difficulty Breathing 197 By Rebecca Hill, DNP, RN, FNP-C, CNE Case 8. 6 Burning Epigastric Pain after Meals 199 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 7 Chest Pain and Dyspnea without Radiation 201 By Rebecca Hill, DNP, RN, FNP-C, CNE and Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, FARN Case 8. 8 Chest Pain with Radiation 205 By Rebecca Hill, DNP, RN, FNP-C, CNE Case 8. 9 Persistent Cough and Joint Tenderness 207 By Rebecca Hill, DNP, RN, FNP-C, CNE Case 8. 10 Morning Headache 209 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Contents ix Case 8. 11 Facial Pain 211 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 12 Fatigue, Confusion, and Weight Loss 213 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 13 Hand Numbness 217 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 14 Chronic Diarrhea 221 By Clara M. Gona, Ph D, FNP-BC, RN and Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 15 Intractable Pain 223 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 8. 16 Wrist Pain and Swelling 225 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Section 9 Mental Health 227 Case 9. 1 Sad Mood 229 By Sheila Swales, MS, RN, PMHNP-BC Case 9. 2 More Than Depression 231 By Sara Ann Jakub, MA, SYC, LPC and Anna Goddard, Ph D, APRN, CPNP-PC Case 9. 3 Postpartum Depression 235 By Nancy M. Terr es, Ph D, RN Case 9. 4 Anxiety 239 By Sheila Swales, MS, RN, PMHNP-BC Case 9. 5 Trauma 241 By Erin Patterson Janicek, LCSW and Anna Goddard, Ph D, APRN, CPNP-PC Section 10 The Older Adult 245 Case 10. 1 Forgetfulness 247 By Amy Bruno, Ph D, RN, ANP-BC Case 10. 2 Behavior Change 251 By Sheila L. Molony, Ph D, APRN, GNP-BC, FGSA, F AAN Case 10. 3 Tremors 255 By Amy Bruno, Ph D, RN, ANP-BC Case 10. 4 Weight Gain and Fatigue 259 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 10. 5 Visual Changes 263 By Millie Hepburn, Ph D, RN, ACNS-BC, SCRN Case 10. 6 Back Pain 267 By Ivy M. Alexander, Ph D, APRN, ANP-BC, F AANP, FAAN Case 10. 7 Acute Joint Pain 273 By Sara Smoller, RN, MSN, ANP-BC | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
x Contents Case 10. 8 Itching and Soreness 275 By Sheila L. Molony, Ph D, APRN, GNP-BC, FGSA, F AAN Case 10. 9 Knee Pain 277 By Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, F ARN Case 10. 10 Hyperthermia and Mental Status Changes in the Elderly 279 By Suellen Breakey, Ph D, RN and Patrice K. Nicholas, DNSc, DHL (Hon), MPH, MS, RN, NP-C, FAAN Section 11 Resolutions 281 Index 591 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xi Contributors EDITOR Leslie Neal-Boylan, Ph D, APRN, CRRN, FAAN, FARN Mansfield Kaseman Health Clinic Rockville, MD, USA CONTRIBUTORS Ivy M. Alexander, Ph D, APRN, ANP-BC, FAANP, FAANProfessor and Director, Adult-Gerontology Primary Care Track Coordinator, Clinical Scholarship School of Nursing University of Connecticut Storrs, CT, USA Nancy Cantey Banasiak, DNP, PPCNP-BC, APRN Associate Professor Yale University School of Nursing New Haven, CT, USA Vera Borkowski, MSN, APRN, FNP-C Family Nurse Practitioner Child and Family Agency of Southeastern CTNew London, CT, USA Suellen Breakey, Ph D, RN Associate Professor School of Nursing MGH Institute of Health Professions Boston, MA, USA | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xii Contributors Amy Bruno, Ph D, RN, ANP-BC Term Lecturer School of Nursing MGH Institute of Health Professions Boston, MA, USA Adult Nurse Practitioner Galileo Health New York, NY, USA Jessica Chan, MSN, APRN, PPCNP-BC Coordinator of Medical Services Child and Family Agency of Southeastern CTNew London, CT, USA Karen M. Flaherty, MSN, MEd, APRN-BC, CBCN Instructor, Academic Support Counselor School of Nursing MGH Institute of Health Professions Boston, MA, USA Betsy Gaffney, MSN, APRN, FNP-BC Family Nurse Practitioner Child and Family Agency of Southeastern CTNew London, CT, USA Anna Goddard, Ph D, APRN, CPNP-PC Assistant Professor College of Nursing Sacred Heart University Fairfield, CT, USA Pediatric Nurse Practitioner Child and Family Agency of Southeastern CTNew London, CT, USA Clara Gona, Ph D, FNP-BC, RN Assistant Professors School of Nursing MGH Institute of Health Professions Boston, MA, USA Allison Grady, MSN, APNP Clinical Instructor College of Nursing University of Wisconsin-Milwaukee Milwaukee, WI, USA Pediatric Nurse Practitioner Medical College of Wisconsin/Children's Wisconsin Clinics Milwaukee, WI, USA Millie Hepburn, Ph D, RN, SCRN, ACNS-BC Assistant Professor Quinnipiac University Hamden, CT, USA | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Contributors xiii Rebecca Hill, DNP, RN, FNP-C, CNE Assistant Professor School of Nursing MGH Institute of Health Professions Boston, MA, USA Family Nurse Practitioner Family Doctors, LLCSwampscott, MA, USA Erin Janicek, LCSW Senior Director of Clinical Services Child and Family Agency of Southeastern CTNew London, CT, USA Sara Ann Jakub, MA, SYC, LPC Director of Clinical Services for School-Based Health Centers Director of Quality Assurance Child and Family Agency of Southeastern CTNew London, CT, USA Annette Jakubisin-Konicki, Ph D, ANP-BC, FNP-BC, FAANP Associate Professor Director, Family Nurse Practitioner Primary Care Track School of Nursing University of Connecticut Storrs, CT, USA Erin Janicek, LCSW Senior Director of Clinical Services Child and Family Agency of Southeastern CTNew London, CT, USA Susan M. Jussaume, MSN, APRN, FNP-BC, AHN-BC Instructor and Family Nurse Practitioner School of Nursing MGH Institute of Health Professions Boston, MA, USA Andrew Konesky, MSN, APRN Pediatric Nurse Practitioner Child and Family Agency of Southeastern CTNew London, CT, USA Jason R. Lucey, DNP, FNP-BC Assistant Professor Family Track Co-Coordinator School of Nursing MGH Institute of Health Professions Boston, MA, USA | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xiv Contributors Antonia C. Makosky, DNP, MPH, ANP-BC, ANP Assistant Professor Adult-Gerontology Primary Care Track Co-Coordinator School of Nursing MGH Institute of Health Professions Boston, MA, USA Mikki Meadows-Oliver, Ph D, RN, FAAN Associate Professor School of Nursing Quinnipiac University Hamden, CT, USA Sheila L. Molony, Ph D, APRN, GNP-BC, FGSA, FAAN Professor of Nursing Quinnipiac University Hamden, CT, USA Patrice K. Nicholas, DNSc, DHL (Hon), MPH, MS, RN, NP-C, FAAN Distinguished Teaching Professor and Director Center for Climate Change, Climate Justice, and Health School of Nursing MGH Institute of Health Professions Boston, MA, USA Meredith Scannell, Ph D, MSN, MPH, CNM, CEN, SANE-A Clinical Research Nurse and Emergency Nurse Brigham and Women's Hospital Boston, MA, USA Sara Smoller, RN, MSN, ANP-BC Assistant Professor School of Nursing MGH Institute of Health Professions Boston, MA Adult Nurse Practitioner Family Doctors, LLCSwampscott, MA, USA Sheila Swales, MS, RN, PMHNP-BC Instructor School of Nursing MGH Institute of Health Professions Boston, MA, USA Nancy M. Terres, Ph D, RN Associate Professor of Nursing School of Nursing MGH Institute of Health Professions Boston, MA, USA | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xv Preface The purpose of this book is to help clinicians and students better understand how to diagnose and manage typical (and some atypical) patient cases. While the focus is on the nurse practitioner role, this book will be useful to other patient care providers, such as physicians and physician's assis-tants. The contributing authors have worked hard to update cases from the first edition of this book to better reflect patient‐centered language and advances in care. We have developed several new cases, such as one on climate change, to assist clinicians with scenarios that were not as pre-dominant as they are today. We have presented a variety of patients in these cases with regard to age, gender identity, socio-economic status, family status, and other considerations. However, please don't hesitate to alter these demographics to tailor the cases for your specific needs. The contributing authors in this book are all subject matter experts. They have written these cases from real life. Consequently, the cases do not result in cookie‐cutter solutions. Critical thinking questions encourage the reader to think carefully about the case as presented and about potential resolutions to the case given variations that occur in real life. These cases should be used to jump‐start conversations among students, faculty, and clinicians regarding possible treatment options depending on the individual patient. All cases include the most current research and guidelines for treatment. The cases are presented chronologically from pediatric to adolescent to adult and older adult. Cases in women's health and men's health have their own separate chapters. Mental health cases are now in a separate chapter. For this second edition we moved the case resolutions to the end of the book. The best use of the book is to read and analyze the case, alter the demographics of the patient to view the case from multiple perspectives, and then review and discuss the resolutions. Keep in mind that there is typically more than one way to treat a patient and patients should always be diagnosed and treated on an individual basis, so there is often more than one possible resolution to a case. We have only included one resolution per case in this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xvii Acknowledgments I am so grateful to the readers of the first edition of this book. Thank you for using it. I hope you will find this second edition even more helpful. Many thanks to the contributing authors of this second edition. Several rejoined me from the first edition and others are new to this edition. All were easy to work with and are consummate professionals and excellent clinicians. Thanks to all the patients and colleagues who've taught me so much throughout the years. Clinical practice and nursing education are my great passions and I'm grateful for all I learn every day. Finally, thank you to Edward and Natalie Rotkoff, Kevin Boylan, Paul Neal, Corinne Neal, Andrew Neal, and Bonnie Brown. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xix Introduction By Leslie Neal‐Boylan, Ph D, APRN, CRRN, FAAN, FARN Family practice is not simply the practice of caring for individuals across the lifespan. Contrary to the perceptions of many students who enter the world of family practice, it is not simply to care for people “from womb to tomb. ” Practice that is guided by that philosophy risks missing so much, not only regarding the individual patient's own health but the family dynamics and the tangible and intangible aspects of the family that impact the individual patient. If the “family” aspect of family practice is ignored or neglected, then the clinician is simply caring for individuals as any clinician would and cannot really style themselves as a family practice clinician regardless of title or certification. To practice as a family practice clinician, it is important to have a basic understanding first about what is meant by “family” and then how the family is integrated into the plan of care and ulti-mately often becomes the “patient. ” In previous work about home health clinicians, this author found that home health clinicians care for the “patient entity,” which is defined as all those who impact or potentially impact the patient's health. In family practice, the clinician also cares for and, at the very least, considers the patient entity when developing and pursuing a plan of care for an individual who seeks health care. The meaning of “family” has undergone significant societal change. Consequently, it is impor-tant that the clinician not make assumptions about who is “family” and who is not. It is important to ask the patient who they consider their family. As I write this, society, both nationally and glob-ally, is undergoing the crisis brought on by the coronavirus. Aside from the medical implications, the virus is already having an impact on how people interact with each other. We are required to practice “social distancing,” which requires us to maintain our relationships, whether personal or professional, in other ways besides close proximity or touching. Neighbors are calling to check in on the elderly, especially those who don't have family nearby, and older adults are checking on the young parents in their neighborhoods who are working from home while trying to manage children who are unable to attend school due to the pandemic. What is the definition of family during a crisis like this? How will we keep each other from becoming socially isolated? Crises like these imply a new definition of family. Technology allows us to keep in contact despite the prohibition on being physically within six feet of another human being. A crisis like this reminds us how vulnerable we are as human beings, not only to disease but to loneliness and despair. Knowing that others care about us takes on even greater significance. We are reminded that “family,” however we define it, is crucial to our survival. As clinicians, we are just as vulnerable but have the advantage of a vast store of medical knowledge. As laypersons disseminate misconceptions about how to prevent and treat the virus, nurse practitioners and our health professions colleagues are stepping up to make sure the public has accurate health care information. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xx Introduction Our care of individuals and families does not just take place in the clinic or health care setting. It occurs via every encounter we have with the people in our communities and across cyberspace. The coronavirus crisis illustrates that while we have better means of communication than in years past, we are also vulnerable to more misinformation. The cases in this book were chosen in an attempt to illustrate mostly typical (and some atypical) cases that occur in family practice. Remembering the impact “family” has on our physical and mental health and that the patient is part of a subsystem within the larger family system can help the reader see that the patient's illness or condition not only impacts the patient but potentially has a ripple effect on many others both within and outside of the family system. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xxi AAA: Abdominal aortic aneurysm AACE: American Association of Clinical Endocrinologists AAP: American Academy of Pediatrics ABG: Arterial blood gas ABI: Ankle brachial index ACC: American College of Cardiology ACIP: Advisory Committee on Immunization Practices ACL: Anterior cruciate ligament ACS: Acute coronary syndr ome ADHD: Attention‐deficit hyperactive disorder ad lib: At liberty or whenever the patient wants to do something AGS: American Geriatrics Society AHA: American Heart Association AMI: Acute myocardial infar ction or heart attack ANA: Anti‐nuclear antibody AP: Anterior‐posterior AP A: American Psychiatric Association Apgar: The score given to newborns at 1 minute and 5 minutes after birth. The newborn is scor ed on activity (muscle tone), pulse, grimace (reflex irritability), appearance (skin color), and respirations. AS: Active surveillance BD: Blastomycoses dermatitidis BDI: Beck Depression Inventory BMI: Body mass index BMP: Basic metabolic panel BP: Blood pressur e BS: Bowel sounds BUN: Blood urea nitr ogen CAD: Coronary artery disease CAM: Complementary and alternative medicine or Confusion Assessment Method CBC: Complete blood count, with or without diff (dif ferential) CBT: Cognitive behavioral therapy CCB: Calcium channel blocker CCRC: Continuing care r etirement community CKD: Chronic kidney disease CLI: Critical limb ischemia Abbreviations and Acronyms | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xxii Abbreviations and Acronyms CLIA: Clinical Laboratory Improvement Amendment CMP: Complete metabolic panel CMT: Cervical motion tenderness COC: Combined oral contraceptive pill COPD: Chronic obstr uctive pulmonary disease COWS: Clinical Opiate Withdrawal Scale CRP: C‐reactive pr otein C‐SSRS: Columbia-Suicide Severity Rating Scale CT: Computed tomography CTA: Clear to auscultation CV A: Cerebr ovascular accident CXR: Chest X‐ray D&C: Dilatation and curettage DASH: Dietary Appr oaches to Stop Hypertension DDV AP: Desmopressin acetate vasopr essin DEA: Drug Enforcement Agency DFA: Direct fluor escent antibody (testing) DMARD: Disease‐modifying antirheumatic dr ug DMPA: Depo‐Pr overa Do D: Department of Defense DOE: Dyspnea on exertion DRE: Digital rectal examination DVT/PE: Deep vein thrombosis/pulmonary embolism DXA: Dual‐energy absorptiometry EBV : Epstein‐Barr virus ECG: Electr ocardiogram ED: Emergency department EEG: Electr oencephalogram ELISA: Enzyme‐linked immunosorbent assay EM: Erythema migrans EMA: Endomysial antibody EMDR: Eye movement desensitization and repr ocessing ENT: Ear, nose, and thr oat EOB: Explanation of benefits EOM: Extraocular movement EPT: Expedited partner therapy ESPGN: European Society for Pediatric Gastr oenterology, Hepatology, and Nutrition ESR: Erythrocyte sedimentation rate ETOH: Alcohol (drinking kind) FBG: Fasting blood glucose FBS: Fasting blood sugar FIT: Fecal immunochemical test FM: Fibr omyalgia FROM: Full range of motion FTT: Failure to thrive GABHS: Group A beta‐hemolytic streptococci GAD: Glutamic acid decarboxylase GC/CHL: Gonorr hea/chlamydia GCA: Giant cell arteritis GCS: Glasgow Coma Scale GDMT: Guideline‐directed medical therapy GDS: Geriatric Depression Scale | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Abbreviations and Acronyms xxiii GERD: Gastroesophageal r eflux disease GFR: Glomerular filtration rate GI: Gastr ointestinal GINA: Global Initiative for Asthma HA1c: Hemoglobin A1c HCV: Hepatitis C virus HPV : Human papilloma virus HR: Heart rate HRI: Heat‐related illness HSDD: Hypoactive sexual desire disor der HSM: Hepatosplenomegaly HSV : Herpes simplex virus H T: Hormone therapy HTN: Hypertension HZO: Herpes zoster opthalmica IBD: Inflammatory bowel disease IBS: Irritable bowel syndrome Ig A: Immunoglobulin A Ig E: Immunoglobulin E ITP: Idiopathic thrombocytopenic purpura IUC: Intrauterine contraception IUD: Intrauterine device KOH: Potassium hydroxide KUB: Kidneys, ureters, and bladder LARC: Long‐acting reversible contraceptives LDH: Lactic acid dehydrogenase LEAP: Learning Early About Peanut LFT : Liver function test LLSB: Left lower sternal border LMP: Last menstrual period LNMP: Last normal menstrual period LR: Light reflex LRI: Lower respiratory infections LROM: Limited range of motion MCI: Mild cognitive impairment MCP: Metacarpal phalangeal (joint) MCV: Mean corpuscular volume MDD: Major depressive disor der MDI: Metered dose inhaler MGF: Maternal grandfather MGM: Maternal grandmother MI: Myocardial infar ction or motivational interviewing MMSE: Mini‐Mental State Examination Mo CA: Montreal Cognitive Assessment MRI: Magnetic resonance imaging MRSA: Methicillin‐r esistant Staphylococcus aureus MSSA: Methicillin‐susceptible Staphylococcus aur eus MSU: Monosodium urate MTP: Metatarsophalangeal (joint) MVI: Multiple vitamin NAAT : Nucleic acid amplification test NAD: No apparent distr ess | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
xxiv Abbreviations and Acronyms NAPNAP: National Association of Pediatric Nurse Practitioners NARES: Nonallergic r hinitis with eosinophilia syndrome NIAAA: National Institute of Alcohol Abuse and Alcoholism NICU: Neonatal intensive care unit NIDA: National Institute on Drug Abuse NKDA: No known drug aller gies NKFA: No known food allergies NOF: National Osteoporosis Foundation NP: Nurse practitioner NPH: Normal pressur e hydrocephalus NSAID: Nonsteroidal anti‐inflammatory dr ug NSTEMI: Non‐ST elevation myocardial infar ction NSVD: Normal spontaneous vaginal delivery NT/ND: Nontender/nondistended OA: Osteoarthritis O2 sat: Oxygen saturation OCP: Oral contraceptive pill ODD: Oppositional defiant disorder OGTT : Oral glucose tolerance test OP: Osteopor osis OSA: Obstructive sleep apnea OTC: Over‐the‐counter (medication) OUD: Opioid use disorder P AD: Peripheral artery disease PCOS: Polycystic ovarian syndrome PCR: Polymerase chain reaction PDA: Patent ductus arteriosus PE: Pulmonary embolism PEG: Polyethylene glycol PEP: Post‐exposure pr ophylaxis PERRLA: Pupils equal, round, r eactive to light and accommodation PGF: Paternal grandfather PGM: Paternal grandmother PH/G: Pubic hair/gonads PHN: Postherpetic neuralgia PHQ: Patient Health Questionnaire PID: Pelvic inflammatory disease PIP: Proximal interphalangeal (joint) PLP: Phantom limb pain PMDD: Premenstr ual dysphoric disorder PMR: Polymyalgia rheumatica PMS: Premenstr ual syndrome PNE: Primary nocturnal enuresis PPD: Postpartum depression PPI: Proton pump inhibitor PRN: As needed PSI: Pneumonia Severity Index PTSD: Post‐traumatic stress disor der PVD: Peripheral vascular disease QD: Once daily RAI: Radionucleotide uptake scan with iodine RED‐S: Relative energy deficiency in sports | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Abbreviations and Acronyms xxv REM: Rapid eye movement RICE: Rest, ice, compression, and elevation ROS: Review of systems RR: Respiratory rate RRR: Regular rate and rhythm RSV : Respiratory syncytial virus RUQ: Right upper quadrant SAFE‐T: Suicide Assessment Five‐Step Evaluation and T riage SAMHSA: Substance Abuse and Mental Health Services Administration SANE: Sexual assault nurse examiner SART : Sexual assault response team SBHC: School‐based health center SBIRT : Screening, Brief Intervention, and Referral for T reatment SEM: Systolic ejection murmur SERM: Selective estrogen r eceptor modulator SGA: Small for gestational age SIB: Self‐injurious behavior SJS: Stevens‐Johnson Syndrome SLE: Systemic lupus erythematosus SM: Stroke mimic SNRI: Serotonin nor epinephrine reuptake inhibitor SSP: Syringe services program SSRI: Selective serotonin r euptake inhibitor STI: Sexually transmitted infection SUD: Substance use disorder SWS: Slow‐wave sleep TANF: Temporary Assistance for Needy Families TBI: Traumatic brain injury or toe brachial index TBSA: Total body surface ar ea TCA: Tricyclic antidepr essant TEN: Toxic epidermal necr osis TENS: Transcutaneous electrical nerve stimulation TM: Tympanic membrane TPO: Antithydroper oxidase antibody TRAb: Thyrotr opin receptor antibody TRUS: Transr ectal ultrasound TSH: Thyroid‐stimulating hormone t TG: Tissue transglutaminase TTN: Transient tachypnea of the newborn TTP: Tenderness to palpation U LT: Urate‐lowering therapy URI: Upper respiratory infection USPSTF: U. S. Preventive Services T ask Force UTI: Urinary tract infection VA : Veterans Administration VCF: Vertebral compr ession fracture VCUG: Voiding cystour ethrography VDRL: Vener eal disease research laboratory VZV: Varicella zoster vir us WBC: White blood cell WHI: Women's Health Initiative WIC: Women, Infants, and Childr en Supplemental Nutrition Program | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Neonate Case 1. 1 Cardiovascular Screening Exam 3 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 1. 2 Pulmonary Screening Exam 7 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 1. 3 Skin Screening Exam 11 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 1. 4 Oxygenation 15 By Mikki Meadows‐Oliver, Ph D, RN, FAAN Case 1. 5 Nutrition and Weight 19 By Mikki Meadows‐Oliver, Ph D, RN, F AANSection 1 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 3SUBJECTIVE Justin, a 10‐day‐old male, presents in the primary care office for a weight check. He is accompa-nied by his parents. His mother is concerned about his feeding habits. She believes that he takes awhile to drink his formula—longer than his siblings did; she also thinks that he sweats more than they did, even when he doesn't feel warm. Birth history: Significant for a 36‐week gestation. His birth weight was 2600 grams. Because of his premature birth, Justin required hospitalization for the first week of life in the Neonatal Intensive Care Unit (NICU). During his stay in the NICU, he was noted to feed without problems, maintain his temperature without assistance, and gain weight. His weight at discharge from the hospital 3 days ago was 2400 grams. Because of his premature birth status and his decreased weight, the family was told to follow up with their primary care provider in 3 days. In the office today, his weight is 2490 grams. Further questioning about Justin's birth history reveals that the mother's pregnancy was normal. She had no infections, falls, or known exposures to environ-mental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. During labor, she experienced a failure to progress, which resulted in her having a cesarean birth. The baby's Apgar scores were 8 at 1 minute and 9 at 5 minutes. Social history: Justin was born to a single, 29‐year‐old mother. His father is involved but does not reside in the household. Justin lives in an apartment with his mother and two other siblings (ages 2 and 4 years). The maternal grandmother (MGM) lives nearby and is able to help Justin's mother provide care. The family receives several governmental subsidies such as the Women, Infants, and Children (WIC) Supplemental Nutrition Program, Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, Justin's mother has a high school diploma. She works in a local retail store. Justin's father works in a manufacturing plant. The family has no pets. The MGM smokes but does not smoke in the home. Diet: Breastfeeding ad lib with supplementation of a milk‐based formula. Elimination: 6-8 wet diapers daily with 3-4 yellow, seedy bowel movements. Sleep: Sleeps between feedings. Case 1. 1 Cardiovascular Screening Exam By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
4 The Neonate Family medical history: PGF (age 54): diabetes mellitus, heart attack at age 50; PGM (age 53): healthy; MGF: deceased from stroke at age 47; MGM (age 54): asthma; mother (age 29): asthma; father (age 31): healthy; Sibling #1 (age 4): asthma; Sibling #2 (age 2): heart murmur. Medications: Currently taking no prescription, herbal, or OTC medications. Allergies: No known allergies to food, medications, or environment. OBJECTIVE Vital signs: Weight: 2490 grams; length: 44 centimeters; temperature: 37°C (rectal). General: Alert, well‐nourished, well‐hydrated baby. Skin: Clear with no lesions noted; no cyanosis of lips, nails, or skin; no diaphoresis noted; skin turgor with elastic recoil. Head: Normocephalic; anterior fontanel open and flat (2 cm × 3 cm); posterior fontanel open and flat (1 cm × 1 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils patent; no discharge. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 28; clear in all lobes; no adventitious sounds noted; no retractions; no defor-mities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; thrill noted in pulmonic area; continuous, systolic, grade 3 heart murmur noted on exam in the pulmonic area of the chest with both the bell and diaphragm; no radiation of the murmur to the back or axilla; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Umbilical cord is in place with no signs and symptoms of infection. Genitourinary: Normal male; testes descended bilaterally; circumcision healing well. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well perfused; capillary refill <2 seconds. Negative hip click. Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Chest X‐ray (CXR)___Echocardiogram___Electrocardiogram | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Cardiovascular Screening Exam 5 What is the most likely differential diagnosis and why? ___Patent ductus arteriosus___Venous hum___Atrioventricular malformation What is the plan of treatment, and what should be the plan for follow‐up care?Are there any referrals needed?Does this patient's psychosocial history influence how you might treat her?What if this baby were a girl?What if this baby had been born full term?What if this baby had been born at a higher altitude?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 7SUBJECTIVE Cassidy, a 12‐hour‐old female, was born at home via planned home birth. She was brought into the office for an initial health maintenance visit. On initial examination, she was found to have rapid breathing when the office nurse weighed her. Cassidy is accompanied by both parents. There are no parental concerns. Birth history: Cassidy is the product of a 40‐week gestation. She was delivered vaginally at home by a certified nurse midwife. During the pregnancy, Cassidy's mother had no falls, infections, or known exposures to environmental hazards. She did not drink alcohol, take prescription medica-tion (other than prenatal vitamins), use tobacco products, or use illicit drugs. The total labor dura-tion was 2 hours. Cassidy's birth weight was 3380 g and her Apgar scores were 9 at 1 minute and 9 at 5 minutes. Social history: Cassidy was born to a 37‐year‐old mother. Cassidy is the second child and has a 3‐year‐old sibling. She lives at home with both parents and her older sibling. The family employs an au pair who also resides in the home. Both parents are college educated. The mother works as a research assistant, and the father works as an accountant. There are no pets or smokers in the home. Diet: Breastfeeding ad lib, but mother feels that Cassidy is having problems latching on. Colostrum is present. Milk has not come in yet. Elimination: Urinated at birth, and has had 3 wet diapers since that time. Passed meconium at 10 hours of age. Sleep: Sleeps between feedings. Family medical history: PGF (age 67): sarcoidosis; PGM (age 63): healthy; MGF (age 64): Type 2 diabetes; MGM (age 64): history of MI at age 63; mother (age 37): healthy; father (age 42): healthy; Sibling #1 (age 3): healthy; history of bronchiolitis. Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Allergies: No known allergies to food, medications, or environment. Case 1. 2 Pulmonary Screening Exam By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
8 The Neonate OBJECTIVE Vital signs: Weight in the office today is 3360 g; length: 48 cm; temperature: 37. 2°C (rectal); pulse oximeter reading: 95% on room air. General: Alert, active baby. Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; skin turgor intact. Head: Molding present; anterior fontanel open and flat (2 cm × 2 cm); posterior fontanel open and flat (1 cm × 1 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils patent; no discharge; mild nasal flaring. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 68; crackles present in lower lung fields bilaterally; mild intercostal retractions; no grunting. No deformities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Umbilical cord is in place with no signs and symptoms of infection. Genitourinary: Normal female genitalia. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click. Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, gag, plantar, palmar, and Babinski reflexes. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Chest radiograph___Arterial blood gas (ABG)___Pulmonary function tests What is the most likely differential diagnosis and why? ___Transient tachypnea of the newborn___Pneumonia___Neonatal sepsis | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Pulmonary Screening Exam 9 What is the plan of treatment, referral, and follow‐up care? Are there any demographic characteristics that would affect this case?What if the patient lived in a rural, isolated setting? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 11SUBJECTIVE Siobhan is a 4‐day‐old infant in the office with her mother for an initial visit and weight check. Her mother states that Siobhan has a rash on her chest and arms that has been intermittent for the past 2 days. There do not seem to be any triggers for the rash. Siobhan's mother has washed all of the baby's clothes in a hypoallergenic cleanser only and has not used any moisturizers on the skin since the baby was discharged from the hospital. The rash also appears when Siobhan is clad in only a diaper. The rash does not appear to cause discomfort for Siobhan. Siobhan's mother has not found anything that makes the rash better or worse. Birth history: Siobhan is the product of a 40‐week gestation. Her birth weight was 3600 g. Further questioning about Siobhan's birth history reveals that the mother's pregnancy was normal. She had no infections, falls, or known exposures to environmental hazards. She did not use alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. During labor, Siobhan's mother received a narcotic analgesic 1 hour prior to birth. Siobhan was deliv-ered via spontaneous vaginal delivery and her Apgar scores were 7 at 1 minute and 9 at 5 minutes. Social history: Siobhan was born to a single, 18‐year‐old mother. Siobhan's father is involved but does not reside in the household. Siobhan lives in a 2‐bedroom apartment with her mother and maternal grandmother (MGM). The MGM is able to help Siobhan's mother provide care. Siobhan's mother receives several governmental subsidies such as the Women, Infants, and Children (WIC) Supplemental Nutrition Program, Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, Siobhan's mother is completing coursework for her high school diploma. Siobhan's father is also a high school student. There are no smokers in the home. The family has a dog. Diet: Siobhan is being fed a milk‐based formula—2 oz every 3-4 hours. Elimination: 6-8 wet diapers daily with 3-4 yellow, seedy bowel movements. Sleep: Sleeps between feedings. Family medical history: PGF (age 40): asthma; PGM (age 38): obesity, high cholesterol, hyperten-sion; MGF (age 36): sickle cell trait; MGM (age 34): bipolar disorder; mother (age 18): sickle cell trait; father (age 17): eczema. Case 1. 3 Skin Screening Exam By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
12 The Neonate Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Allergies: No known allergies to food, medications, or environment. OBJECTIVE Vital signs: Weight: 3690 g; length: 44 cm; temperature: 36. 8°C (rectal). General: Alert, well‐nourished, well‐hydrated baby. Skin: Scattered 1‐cm, yellow‐white papules on an erythematous base on the trunk, upper arms, and thighs; lesions are nontender to touch; lanugo over shoulders; no cyanosis of lips, nails, or skin; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanel open and flat (0. 3 cm × 3 cm); posterior fontanel open and flat (0. 5 cm × 0. 5 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils patent; no discharge. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 28; clear in all lobes; no adventitious sounds noted; no retractions; no defor-mities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Umbilical cord is in place without signs and symptoms of infection. Genitourinary: Normal male; testes descended bilaterally; circumcision healing well. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click. Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Skin biopsy___Peripheral blood smear___Bacterial/viral culture from the lesion | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Skin Screening Exam 13 What is the most likely differential diagnosis and why? ___Milia___Erythema toxicum___Herpes simplex virus What is the plan of treatment?Does the patient's psychosocial history impact how you might treat her?Are any referrals needed?Are there any demographic characteristics that would affect this case? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 15SUBJECTIVE Matthew, a 27‐day‐old infant, arrives at the office with complaints of “breathing fast” and conges-tion since yesterday. He is accompanied by both parents. He has had no fever. At home, his rectal temperature was 37. 2 degrees this morning. The parents tried using a humidifier to alleviate the symptoms, but they do not feel that this helped. They also used a bulb syringe with nasal saline to help relieve nasal congestion. Matthew has had several visitors at his home during the first few weeks of his life, including small children who attend day‐care centers. His mother thinks that some of those visitors may have had cold symptoms, although she tried to keep anyone who seemed sick away from Matthew. Diet: Normally breastfeeding every 2-3 hours; occasionally supplementing with a milk‐based formula. Since yesterday, intake has decreased. Elimination: 4-6 wet diapers since yesterday, which is decreased from his normal urine output. 2-3 bowel movements. Sleep: Normally sleeps approximately 5 hours at night with several naps throughout the day. However, since yesterday, Matthew's sleep has been interrupted. Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Allergies: No known allergies to food, medications, or environment. Birth history: Matthew was the product of a 39‐week gestation. He was delivered via planned cesarean section. Matthew's mother had no falls or known exposures to environmental hazards. She has a history of chlamydia during the pregnancy at 36 weeks' gestation. She was treated with antibiotics. The only other prescription medications taken during the pregnancy were prenatal vitamins. She did not use tobacco products or use illicit drugs. She stated that she drank an occa-sional glass of wine during the third trimester. Matthew's birth weight was 3250 g, and his Apgar scores were 9 at 1 minute and 9 at 5 minutes. Social history: Matthew was born to a 32‐year‐old mother. He lives at home with both parents. Neither parent has any other children. The mother works as a secretary, and the father works in construction. Matthew's father is a smoker. The family has 2 cats. Case 1. 4 Oxygenation By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
16 The Neonate Family medical history: PGF (age 65): Type 2 diabetes mellitus; PGM (age 64): breast cancer at age 55; MGF (age 60): asthma; MGM (age 64): healthy; mother (age 32): asthma; father (age 32): seasonal allergies. OBJECTIVE Vital signs: Weight: 4050 grams; length: 48 cm; temperature: 37. 2°C (rectal); pulse oximeter reading: 91% on room air. General: Alert, well‐hydrated, well‐nourished baby in mild respiratory distress. Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanelle open and flat (2 cm × 2 cm); posterior fontanelle open and flat (0. 5 cm × 0. 5 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils congested; cloudy discharge present in nares; mild nasal flaring. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 42; expiratory wheezing present in all lobes; intercostal retractions present; no grunting; no deformities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Genitourinary: Normal male genitalia; testes descended bilaterally. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click. Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? ___Chest radiograph (anterior‐posterior [AP] and lateral views)___Nasopharyngeal swab to detect respiratory syncytial virus (RSV)___Complete blood count | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Oxygenation 17 What is the most likely differential diagnosis and why? ___Bronchiolitis___Upper respiratory infection (URI)___Chlamydial pneumonia What is the plan of treatment, referral, and follow‐up care?What demographic characteristics might affect this case?Does the patient's psychosocial history impact how you might treat him? What if the patient lived in a rural, isolated setting? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 19SUBJECTIVE Anita is a 2‐week‐old Hispanic female in for her well‐child check. She is accompanied by her 15‐year‐old mother. The family speaks only Spanish. A Spanish‐speaking interpreter is used for the visit. Anita's mother is concerned that Anita spits up a lot after eating. The mother states that the vomit is not projectile. The mother is worried that, since the baby is vomiting so much, she is not getting enough food. Therefore, the mother has been feeding Anita even more formula. Also, Anita's mother is worried that she will run out of formula since the baby takes so much. Diet: Formula feeding: 5 oz every 2-3 hours. Elimination: 6 wet diapers and 3 bowel movements since yesterday. Sleep: Sleeps approximately 4 hours at night with several naps throughout the day. Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Allergies: No known allergies to food, medications, environment. Birth history: Anita was the product of a 38‐week gestation. She was delivered via spontaneous vaginal delivery. Anita's mother had no falls, infections, or known exposures to environmental hazards. The only prescription medications taken during the pregnancy were prenatal vitamins. She did not use alcohol, tobacco products, or illicit drugs during the pregnancy. Anita's birth weight was 3250 g and her Apgar scores were 8 at 1 minute and 9 at 5 minutes. Her discharge weight was 3180 g. Social history: Anita lives at home with her teenage mother and her maternal grandmother (MGM), who emigrated from Mexico. The father of the baby is involved. Neither parent has any other children. Both parents are students at a local high school. The family has a dog. Family medical history: PGF (age 37): high blood pressure; PGM (age 33): thyroid problems; MGF (age 35): health history unknown; MGM (age 30): healthy; mother (age 15): healthy; father (age 15): healthy. Case 1. 5 Nutrition and Weight By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
20 The Neonate OBJECTIVE Vital signs: Weight: 4050 g; length: 48 cm; temperature: 37. 3°C (rectal). General: Alert, well‐developed baby. Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanel is open and flat (3 cm × 2 cm); posterior fontanel is open and flat (1. 0 cm × 0. 5 cm). Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils congested; cloudy discharge present in nares; mild nasal flaring. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 24; lungs with clear breath sounds in all lobes; no retractions present; no grunt-ing; no deformities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Genitourinary: Normal female genitalia. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click. Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? ___Upper gastrointestinal (GI) imaging series___Manometry to assess esophageal motility and lower esophageal sphincter function___Complete blood count What is the most likely differential diagnosis and why? ___Overfeeding___Gastroesophageal reflux disease___Gastroenteritis | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Nutrition and Weight 21 What is the plan of treatment and follow‐up care? Does the patient's psychosocial history impact how you might treat this case?What demographic characteristics might affect this case? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Infant Case 2. 1 Nutrition and Weight 25 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 2. 2 Breastfeeding 29 By Mikki Meadows‐Oliver, Ph D, RN, FAAN Case 2. 3 Growth and Development 33 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 2. 4 Heart Murmur 37 By Mikki Meadows‐Oliver, Ph D, RN, F AAN Case 2. 5 Cough 41 By Mikki Meadows‐Oliver, Ph D, RN, FAAN Case 2. 6 Diarrhea 45 By Mikki Meadows‐Oliver, Ph D, RN, FAAN Case 2. 7 Fall from Height 49 By Mikki Meadows‐Oliver, Ph D, RN, F AANSection 2 | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 25SUBJECTIVE Neil, a 12‐month‐old infant, presents to the office for a well‐baby visit. He is accompanied by his mother, Kayla. Kayla states that Neil has been healthy since his last well‐baby visit at 9 months of age. He has had no visits to the urgent care clinic or to the emergency room in the interim. Kayla is concerned that Neil's appetite has diminished. She states that he is not eating as much lately as he had been. Diet: Neil's nutrition history reveals that he has successfully transitioned to a diet with whole milk. He drinks five 8‐oz bottles of whole milk daily. Neil is a “picky eater. ” He rarely eats foods that are offered to him and, instead, prefers to drink from the bottle. He is not currently taking any multivitamins. Elimination: Kayla states that Neil has 4-6 wet diapers daily. He does not have any diarrhea but does have occasional constipation that is relieved with prune juice. Sleep: Neil sleeps 13 hours nightly but does not take any naps during the day. He does not have any problems falling asleep or staying asleep. His nighttime bedtime routine includes a bath and bedtime story read to him by Kayla. Developmental: Neil is able to walk while holding onto furniture. He can also stand unassisted for about 5 seconds. Neil says “dada” and “mama” and has words for bottle and milk. Birth history: Neil was the product of a 37‐week gestation. He was delivered vaginally with the assistance of a vacuum. During the pregnancy, Kayla had no falls or infections. She did not drink alcohol, take over‐the‐counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Neil's birth weight was 3000 g, and his Apgar scores were 8 at 1 minute and 9 at 5 minutes. Past medical history reveals that Neil has had 3 episodes of acute otitis media since birth. He has had no injuries or illnesses requiring visits to the emergency department. Social history: Neil was born to a 20‐year‐old mother. He has a 2‐month‐old younger sibling. He lives at home with his mother and his paternal grandmother. Neil's father is currently incarcerated. Case 2. 1 Nutrition and Weight By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
26 The Infant Neil's mother does not currently work outside the home. The family receives a rent subsidy from Section 8 and a food subsidy from the Women, Infants, and Children (WIC) program and food stamps. The family also receives monthly cash assistance from the Temporary Aid to Needy Families (TANF) program. The family has no pets and there are no smokers in the home. Family medical history: Neil's mother has no health problems. His father is 32 years old and has no history of chronic medical conditions. His maternal grandmother has a history of breast cancer. His maternal grandfather has high blood pressure. His paternal grandmother (48 years of age) is healthy with no health problems. The health history of his paternal grandfather is unknown. Neil is not currently taking any over‐the‐counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required immunizations. OBJECTIVE Neil's vital signs were taken in the office. His weight is 6. 4 kg, and his length is 66 cm. His tem-perature is within the normal range at 36. 8°C (temporal). When observing Neil's general appear-ance, he is alert, active, and playful. He appears well hydrated and well nourished. Skin: Clear of lesions; no cyanosis of his skin, lips, or nails; no diaphoresis noted. Neil has good skin turgor on examination. HEENT: Neil's head is normocephalic. His anterior fontanel is open and flat (0. 5 cm × 0. 5 cm). Red reflex is present bilaterally; and his pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal, and the tympanic membranes are gray bilaterally with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Neil's mucous membranes are noted to be moist when examining his oropharynx. He has 8 teeth present, with white spots present on both upper central incisors. There are no lesions present in the oral cavity. Neck: Supple and able to move in all directions without resistance; shotty nodes present in the posterior cervical region. Respiratory: Respiratory rate is 20 breaths per minute, and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage noted. Cardiovascular: Heart rate is 106 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2+ bilaterally. Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Normal male genitalia. Neil is circumcised and his testes are descended bilaterally. Neuromusculoskeletal: Good tone in all extremities; full range of motion in all extremities. His extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Nutrition and Weight 27 CRITICAL THINKING Which laboratory tests should be ordered as part of a 12‐month, well‐child visit? Other than “well child,” what additional diagnoses should be considered for Neil?What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 29SUBJECTIVE Julio, a 9‐month‐old male, presents to the office for a well‐baby visit. He is accompanied by his mother, Lupita. Lupita is Spanish speaking, so a medical interpreter is used for the visit. Lupita has no concerns and states that Julio has been healthy since his last well‐child visit at 6 months of age. He has had no visits to the urgent care clinic or to the emergency room in the interim. Diet: Julio's nutrition history reveals that he is still being breastfed but that he is also being supple-mented with a low‐iron, milk‐based formula. Lupita states that she gives Julio low‐iron formula because formula that is not low‐iron makes him constipated. He eats a diet of regular food that the family eats. He eats fruits and vegetables daily. Lupita introduced finely chopped meats into Julio's diet last week, and he has tolerated the addition well. Julio also enjoys Cheerios ®, which he is able to grasp and bring to his mouth without assistance. He is not currently taking any multivitamins. Elimination: Lupita states that Julio has 4-6 wet diapers daily and voids easily with a straight urine stream. He does not have any diarrhea or constipation since beginning the low‐iron formula. Sleep: Julio is sleeping 10 hours at night and takes one 2‐hour nap daily. He does not have any problems falling asleep or staying asleep. At night, he has a bedtime routine that includes a bath and bedtime story read to him by an older sibling. Development: Julio is crawling and pulling up to stand. He makes lots of vocalizations and is saying “da‐da,” although Lupita is not sure if he is just making sounds or referring to his father when he says “da‐da. ” Julio has a beginning pincer grasp that allows him to eat small items such as Cheerios ®. Birth history: Julio is the product of a 40‐week gestation. He was delivered vaginally without complications. During the pregnancy, his mother had no falls or infections. Lupita did not drink alcohol, take over‐the‐counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Julio's birth weight was 3500 g, and his Apgar scores were 9 at 1 minute and 9 at 5 minutes. Past medical history reveals that he was hospitalized at 4 months of age for bronchiolitis. He has had no episodes of wheezing since that time. Case 2. 2 Breastfeeding By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
30 The Infant Social history: Julio was born to a 31‐year‐old mother. He has 2 older siblings (7 and 9 years old). He lives at home with both parents and his maternal grandfather. The family is from Ecuador. His mother works as a housekeeper, and his father works in construction. The family has a pet bird. There are no smokers in the home. Family medical history: Julio's mother has asthma and seasonal allergies. His 33‐year‐old father is healthy and has no history of chronic medical conditions. Julio's maternal grandmother died at age 55 years from a myocardial infarction. His maternal grandfather has a history of Type 2 diabetes mellitus and obesity. His paternal grandparents are both deceased; both died in a motor vehicle accident several years ago. Julio is not currently taking any over‐the‐counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required immunizations. OBJECTIVE Julio's vital signs were taken in the office today. His weight is 6. 0 kg, and his length is 64 cm. Julio's temperature is within the normal range at 37°C (temporal). When observing his general appearance, he is alert, active, and playful. He appears well hydrated and well nourished. Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There was no dia-phoresis noted. Julio has good skin turgor on examination. HEENT: Julio's head is normocephalic. His anterior fontanel is open and flat (0. 5 cm × 0. 5 cm). Red reflexes are present bilaterally and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; tympanic membranes are gray bilaterally with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Julio's mucous membranes are noted to be moist when examining his oropharynx. He has 2 teeth present without evidence of caries. There are no lesions present in the oral cavity. Neck: Supple and able to move in all directions without resistance. There is no cervical lymphadenopathy. Respiratory: Respiratory rate is 22 breaths per minute and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiovascular: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2+ bilaterally. Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Genitourinary examination reveals normal male genitalia. Julio is uncircumcised, and his testes are descended bilaterally. Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities. His extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Breastfeeding 31 CRITICAL THINKING Which laboratory or diagnostic imaging tests should be ordered as part of a 9‐month, well‐child visit? ___CBC___Lead screening test___Liver function tests___Cholesterol level___Baseline chest radiograph What is the most likely differential diagnosis and why? ___Iron deficiency anemia___Constipation___Other What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 33SUBJECTIVE Kilah, a 9‐month‐old infant, presents to the office for a well‐baby visit. She is accompanied by her foster mother, Angela. Angela states that Kilah has been in her care for the past 7 months. Kilah is the first infant that Angela has cared for. According to Angela, Kilah has been healthy since her last well‐child visit at 6 months of age. She has had no visits to the urgent care clinic or to the emergency room in the interim. Angela is concerned that Kilah appears thin. Diet: Kilah's nutrition history reveals that she drinks three 8‐oz bottles of milk‐based formula daily. Kilah also eats 1 jar of stage 1 baby food twice daily. She is not currently taking any multivitamins. Elimination: Angela states that Kilah has 4-6 wet diapers daily. She does not have any diarrhea or constipation. Sleeps: Kilah sleeps 10 hours nightly and takes 2 naps daily. Angela states that Kilah does not have any problems falling asleep or staying asleep. The family does not currently have a bedtime routine for Kilah. Birth history: Angela does not know any of the details of Kilah's birth history or family history. Past medical history: Kilah has been healthy since being placed in Angela's care. Since placement, Kilah has had no injuries or illnesses requiring visits to the emergency department. Developmentally, Kilah is able to crawl. She is able to pick up small objects such as Cheerios ® using only her thumb and forefinger. Kilah makes many sounds and is beginning to say “dada. ” Social history: Kilah lives at home with her foster mother, Angela. Angela does not currently work outside the home. The family receives a rent subsidy from Section 8, food subsidies from the Women, Infants, and Children (WIC) program, and food stamps. The family also receives monthly cash assistance from the Temporary Aid to Needy Families (TANF) program. The family has no pets, and there are no smokers in the home. Medications: Kilah is not currently taking any over‐the‐counter, prescription, or herbal medications. Allergies: Kilah has no known allergies to food, medications, or the environment. She is up to date on required immunizations. Case 2. 3 Growth and Development By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
34 The Infant OBJECTIVE General: Appears thin but alert, active, and playful. Vital signs: Weight in the office today is 6. 4 kg and her length is 66 centimeters. Kilah's temper-ature is within the normal range at 36. 8°C (temporal). Kilah's weight has not changed since her last well child visit. Skin: She appears well hydrated, and her skin was clear of lesions. There is no cyanosis of her skin, lips, or nails. There was no diaphoresis noted. Kilah has good skin turgor on examination. HEENT: Kilah's head is normocephalic. Her anterior fontanel is open and flat (0. 5 cm × 0. 5 cm). Red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal; the tympanic membranes were gray bilaterally with positive light reflexes. Bony landmarks are visible and there was no fluid noted behind the tympanic mem-brane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Kilah's mucous membranes are noted to be moist when examining her oropharynx. She has 2 teeth present—lower central incisors. There are no lesions present on the teeth or in the oral cavity. Neck: Supple and able to move in all directions without resistance. There are no lymph nodes present in the neck area. Respiratory: Rate is 22 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. There are no deformities of the thoracic cage noted. Cardiovascular: Heart rate is 110 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2+ bilaterally. Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Genitourinary examination reveals normal female genitalia. Neuromusculoskeletal: Good tone in all extremities. She has full range of motion in all extremities and her extremities are warm and well perfused. Capillary refill is less than 2 seconds, and her spine is straight. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? ___CBC count___Urinalysis___Urine culture___Electrolytes, including creatinine and BUN___Liver function tests, including total protein and albumin___Barium swallow___Chest radiograph | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Growth and Development 35 What is the most likely differential diagnosis and why? ___Organic failure to thrive (FTT)___Nonorganic FTT (FTT)___Constitutional growth delay___Fetal alcohol spectrum disorder What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 37SUBJECTIVE Jonathan, a 12‐month‐old infant, presents to the primary care office for a well‐child visit. He is accompanied by his parents. His mother is concerned that Jonathan is eating less than usual but says that he is drinking his normal amount. His activity level has not changed. Birth history: Jonathan was born at 39 weeks' gestation. His birth weight was 3200 g. There were no complications during the labor or delivery. The mother had no infections, falls, or known expo-sures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. The immediate neonatal period was unremarkable. Jonathan was discharged at 2 days of age to home with his mother. The social history reveals that Jonathan was born to a 23‐year‐old single mother. His father is involved but does not reside in the household. Jonathan lives in an apartment with his mother and 19‐year‐old cousin. The maternal grandmother (MGM) lives in the neighborhood and is able to help Jonathan's mother with child care. The family receives assistance from governmental sub-sidies such as the Women, Infants, and Children supplemental nutrition program (WIC), Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, both Jonathan's mother and father have high school diplomas. She works at a fast‐food restaurant. Jonathan's father works as a construction worker. The family has no pets. There are no smokers in the home. Diet: Jonathan eats a balanced diet of table foods. He still breastfeeds but is transitioning to whole milk. He takes a daily multivitamin. Elimination: 4-6 wet diapers daily with 1 bowel movement. Sleep: Takes one 2‐hour nap daily and sleeps 12 hours at night. Family medical history: PGF (age 54): healthy; PGM (age 53): diabetes mellitus; MGF (age 46): high blood pressure; MGM (age 44): asthma; mother (age 23): asthma; father (age 32): healthy. Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Immunizations: Up to date. Allergies: No known allergies to food, medications, or environment. Case 2. 4 Heart Mur mur By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
38 The Infant OBJECTIVE Vital signs: Weight: 10 kg; length: 84 cm; temperature: 37°C (axillary). General: Alert; well nourished; well hydrated; interactive. Skin: Clear with no lesions noted; no cyanosis of lips, nails, or skin; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanel is open and flat (1 cm × 1 cm). Eyes: Red reflexes present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils are patent; no discharge. Oropharynx: Mucous membranes are moist; no teeth are present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 24; clear in all lobes; no adventitious sounds noted; no retractions; no defor-mities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; vibratory, systolic, grade 2 heart murmur noted on exam at the lower left sternal border area of the chest with both the bell and diaphragm; heard best in the supine position; no heaves or thrills noted; no radiation of the murmur to the back or axilla; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Genitourinary: Normal circumcised male genitalia; testes descended bilaterally. Back: Spine straight. Ext: Full range of motion of all extremities; warm and well perfused; capillary refill < 2 seconds. Neurologic: Good strength and tone. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? ___Chest radiograph___Echocardiogram___Electrocardiogram What is the most likely differential diagnosis and why? ___Patent ductus arteriosus (PDA)___Ventricular septal defect (VSD)___Still's murmur | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Heart Murmur 39 What is the plan of treatment, referral, and follow‐up care? Are there any referrals needed?Does the patient's psychosocial history impact how you might treat him?What if this baby were a girl?What if this baby were 6 months old? Are there any standardized guidelines that should used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 41SUBJECTIVE Katelynn, a 7‐month‐old infant, presents to the office with complaints of cough for 2 days and “breathing heavy” since this morning. Katelynn is accompanied by both parents. She has had a fever for 2 days. Her maximum temperature at home was 101°F (rectal). She also has a runny nose. Her mother has tried an over‐the‐counter cough medicine without much relief. Katelynn's mother has not found much that helps the symptoms; but she notices that, when Katelynn cries, the breathing sounds get worse. Katelynn attends day care and her mother states that many of the kids there have coughs and runny noses. Katelynn's mother also has had cold symptoms for nearly 5 days. Birth history: Katelynn was the product of a 40‐week gestation. She was delivered vaginally without complications. During the pregnancy, Katelynn's mother had no falls, infections, or known exposures to environmental hazards. She did not drink alcohol, take over‐the‐counter or prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. Katelynn's birth weight was 3300 g and her Apgar scores were 9 at 1 minute and 9 at 5 minutes. Social history: Katelynn was born to a 31‐year‐old mother. Katelynn has a 2‐year‐old sibling. She lives at home with both parents and her older sibling. Both parents have high school diplomas. The mother works as an administrative assistant, and the father works as a maintenance worker. There are no pets or smokers in the home. Diet: Decreased solid and liquid intake since yesterday. Elimination: Decreased urine output; no diarrhea or constipation. Sleep: Sleep is interrupted by coughing. Family medical history: Paternal grandfather (PGF) (age 60): history of prostate cancer; paternal grandmother (PGM) (age 59): healthy; maternal grandfather (MGF) (age 61): Type 2 diabetes mellitus, high cholesterol, high blood pressure; maternal grandmother (MGM) (age 61): asthma; mother (age 31): asthma; father (age 30): healthy; sibling (age 2): healthy; history of bronchiolitis. Medications: Currently taking no prescription or herbal medications. Taking a children's over‐ the‐counter cough suppressant. Case 2. 5 Cough By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
42 The Infant Immunizations: Up to date. Allergies: No known allergies to food, medications, or environment. OBJECTIVE Vital signs: Weight: 7. 1 kg; length: 65 cm; temperature: 37. 9°C (rectal); pulse oximeter reading: 95% on room air. General: Alert, active, well‐hydrated, interactive baby. Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanel is open and flat (1. 5 cm × 1. 5 cm). Eyes: Red reflexes present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils patent; no discharge; mild nasal flaring. Oropharynx: Mucous membranes moist; no teeth present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 32; barking cough noted; inspiratory stridor with activity; no intercostal, supra‐sternal, or subcostal retractions; no grunting; no deformities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Genitourinary: Normal female genitalia. Back: Spine straight. Extremities: Full range of motion of all extremities; warm and well perfused; capillary refill < 2 seconds. Neurologic: Good tone in all extremities. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? ___Chest X‐ray (CXR)___Arterial blood gas (ABG)___Complete blood count (CBC) | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Cough 43 What is the most likely differential diagnosis and why? ___Croup (laryngotracheobronchitis)___Bronchiolitis___Epiglottitis What is the plan of treatment, referral, and follow‐up care?Are there any demographic characteristics that would affect this case? What if the patient lived in a rural, isolated setting? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 45SUBJECTIVE David, an 11‐month‐old infant, presents to the office with complaints of watery diarrhea for 1 day. David is accompanied by his mother. In addition to the diarrhea, he has had vomiting for 1 day and a fever for 2 days. His maximum temperature at home was 102°F (rectal). David has not vomited today, although the fever continues and the diarrhea seems to be getting worse. He has had at least 10 diapers with diarrhea since yesterday. David's mother is unsure of his urine output because each diaper is so full of stool. No blood or mucus has been noted in the stool. His mother believes that a rash is starting on his buttocks due to the diarrhea. She knows that another child in the day care center had diarrhea a few days ago. No one at home has any similar symptoms. Yesterday, David completed a course of amoxicillin for otitis media. David's mother states that earlier in the week she began to introduce whole milk into his diet and that she also gave him Indian take‐out food with a strong curry flavor. She is concerned that one of these factors may have caused or contributed to David's diarrhea. Further review of systems reveals that David has had decreased solid food and soy formula intake since yesterday and that he has been sleeping more than usual. Birth history: David is the product of a 41‐week gestation. He was delivered vaginally without complications. During the pregnancy, his mother had no falls or infections. She was in a car accident when she was 6 months pregnant and had to receive an X‐ray of her right wrist. There was no break in the wrist, and she was told to take Tylenol for pain. David's mother did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. His birth weight was 3480 g, and his Apgar scores were 7 at 1 minute and 8 at 5 minutes. Social history: David was born to a 39‐year‐old mother. He is an only child. He lives at home with his mother. She works as a psychologist with her own private practice. David's father is not involved. There are no pets or smokers in the home. Family medical history: The health history of David's father and the paternal grandparents is unknown. David's mother is positive for Crohn disease. His maternal grandmother has a history of Type 2 diabetes, and the maternal grandfather has a history of prostate cancer. David is currently taking no prescription or herbal medications. His mother gave him an over‐ the‐counter antiemetic, Emetrol ®, to help reduce nausea and vomiting. She has not given him any Case 2. 6 Diarrhea By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
46 The Infant antidiarrheal agents. David has no known allergies to food, medications, or the environment. He is up to date for required vaccinations, but he did not receive a rotavirus vaccination due to a recall of the vaccination. OBJECTIVE David's vital signs were taken in the office today. His weight is 6. 8 kg, and his length is 69 cm. David's temperature is elevated at 38°C (rectal). When observing David's general appearance, he is alert and consolable by his mother when crying. Skin: The skin on David's buttocks is mildly erythematous. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted. David has good skin turgor on examination. HEENT: David's head is normocephalic. His anterior fontanel is open and flat (0. 5 cm × 0. 5 cm). Upon examination of David's eyes, his red reflexes are present bilaterally and his pupils are equal, round, and reactive to light. There is no discharge noted, and tears are present when crying. David's external ear reveals that the pinnae are normal. On otoscopic examination, the tympanic membranes are pink bilaterally with positive light reflex. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. David's mucous membranes are noted to be moist when examining his oropharynx. He has 4 teeth present without evidence of caries. There are no lesions present in the oral cavity. Neck: David's neck is supple and able to move in all directions without resistance. There is no cervical lymphadenopathy. Respirations: Respiratory rate is 28 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No defor-mities of the thoracic cage are noted. Cardiovascular: Heart rate is 110 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Brachial and femoral pulses are present and 2+ bilaterally. Abdomen: Hyperactive bowel sounds are present throughout. David has diffuse tenderness on abdom-inal palpation. His abdomen is mildly distended; there is no evidence of hepatosplenomegaly. Genitourinary: Genitourinary examination revealed normal male genitalia. David is circumcised, and his testes are descended bilaterally. Neuromusculoskeletal: David was noted to have good tone in all extremities. He has full range of motion of all extremities. His extremities are warm and well perfused. Capillary refill is less than 2 seconds. David's spine is straight. CRITICAL THINKING Which laboratory or imaging studies should be considered to assist with or confirm the diagnosis? ___Complete blood count (CBC)___Stool culture___Electrolyte levels___Hydrogen breath test___Lactose tolerance test | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Diarrhea 47 What is the most likely differential diagnosis and why? What is the plan of treatment, referral, and follow‐up care?Are there any demographic factors that should be considered? Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 49SUBJECTIVE Victor, a 2‐month‐old infant, presents in the office for an examination after he fell off the changing table. He is accompanied by his mother, Amy. Amy states that she was preparing to change Victor's diaper, and she placed him on the changing table. She then realized that she had forgotten to bring the diaper wipes to the changing table. When she turned around to retrieve the wipes, Victor rolled off the table and onto the floor. Amy states that Victor cried immediately after falling. She did not notice any bleeding after the fall but she did notice bruising on the left side of Victor's head, which prompted her to bring him in to the office. The injury occurred approximately 1 hour ago. Since that time, Victor has not had anything to eat or drink. He has not had any wet diapers. Amy stated that she did not let Victor sleep after his head injury. Diet: Normally, Victor takes six 4‐oz bottles of soy‐based formula daily. He has not yet started any solids. Elimination: Amy states that Victor normally has 6-8 wet diapers daily. He has 2 bowel move-ments daily. Amy denies that Victor has diarrhea or constipation. Sleep: Victor normally sleeps 2-3 hours at a time between feedings. He has one 5‐hour stretch of sleep during the night. Birth history: Victor is the product of a 40‐week gestation. He was born via spontaneous vaginal delivery. During the pregnancy, Amy had no falls or infections. She did not drink alcohol, take over‐the‐counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. His birth weight was 3280 g, and his Apgar scores were 9 at 1 minute and 9 at 5 minutes. Since birth, he has had no other injuries or illnesses. Social history: Victor was born to an 18‐year‐old mother. He lives at home with his mother and his maternal grandmother. Victor's father is not involved in his care. His mother does not currently work outside the home but plans to return to work at a local fast‐food restaurant soon. She is looking for child care. The family receives a rent subsidy from Section 8, food subsidies from the Women, Infants, and Children (WIC) program, and food stamps. The family also receives monthly cash assistance from the Temporary Aid to Needy Families (TANF) program. The family has no pets, and there are no smokers in the home. Case 2. 7 Fall from Height By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
50 The Infant Family medical history: Victor's mother has no health problems. His father is 17 years old and has no history of chronic medical conditions. His maternal grandmother (38 years of age) has a history of high blood pressure. His maternal grandfather (39 years of age) also has high blood pressure. His paternal grandmother (48 years of age) is healthy with no health problems, and his paternal grandfather's health history is unknown. Medications: Victor is not currently taking any over‐the‐counter, prescription, or herbal med-ications. He has no known allergies to food, medications, or the environment. He has not yet received any recommended immunizations other than the hepatitis B vaccination received at 1 day of age. OBJECTIVE Victor's vital signs are taken, and his weight in the office today is 5. 24 kg. His temperature is within the normal range at 37. 1°C (rectal). He is alert, active, and playful. He appears well hydrated and well nourished. Skin: His skin shows a 1. 5 cm × 1. 0 cm area of ecchymosis over the left forehead. The area appears mildly tender to touch. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and he has good skin turgor on examination. HEENT: Normocephalic with no swelling of the scalp. His anterior fontanel is open and flat (2 cm × 2 cm). Victor's red reflexes are present bilaterally; and his pupils are equal, round, and reactive to light. He is able to fix and follow the examination past midline. There is no ocular discharge noted. The external ear reveals that the pinnae are normal. On otoscopic examination, the tympanic membranes are gray bilaterally with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There are no nasal discharge and no nasal flaring. Victor's mucous membranes are noted to be moist when examining his oropharynx. He has no teeth, and there are no lesions present in the oral cavity. Neck: Victor's neck is supple and able to move in all directions without resistance. He has no cervical lymphadenopathy. Respiratory: Respiratory rate is 24 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No defor-mities of the thoracic cage are noted. Cardiovascular: Heart rate is 116 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. When palpating, brachial and femoral pulses are present and 2+ bilaterally. Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Normal male genitalia. Victor is uncircumcised and his testes are descended bilaterally. Neuromusculoskeletal: Good tone in all extremities; full range of motion in all extremities. His extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Fall from Height 51 CRITICAL THINKING Which laboratory tests should be ordered as part of a workup after a fall from height? What is the most likely differential diagnosis and why?What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 3 The Toddler/Preschool Child Case 3. 1 Earache 55 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 2 Bedwetting 57 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 3 Burn 61 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 4 Toothache 63 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 5 Abdominal Pain 67 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 3. 6 Lesion on Penis 71 By Mikki Meadows-Oliver, Ph D, RN, F AAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 55SUBJECTIVE Janice, a 3‐year‐old preschool child, presents to the office with a complaint of left ear pain for 2 days. She is accompanied by her mother, Marsha. She has had an intermittent fever and her maximum temperature at home was 101°F (axillary). The pain is worse sometimes when she is lying down. The pain is occasionally relieved with the use of over‐the‐counter pain relievers. Janice has had no vomiting or diarrhea. She has had a slight runny nose, but no cough. Diet: Janice's nutrition history reveals that she has a balanced diet with enough dairy, protein, fruits, and vegetables. Her appetite has decreased over the past 2 days since the ear pain began. Elimination: She is voiding well with no complaints of dysuria. Sleep: Janice sleeps approximately 10 hours at night and takes one 1‐hour nap at her preschool. She usually has no problems falling or staying asleep but since the ear pain has started, her sleep has been interrupted. Past medical history: Janice was born via vaginal delivery at 40 weeks' gestation. Since being discharged at 2 days of age, she has had no emergency department (ED) visits or hospitalizations. Janice has had 2 episodes of otitis media that were cleared with antibiotics. She has had no injuries or illnesses since that time. Janice passed her developmental screening at her last well‐child visit. She currently attends preschool and is doing well, according to Marsha. She has no chronic ill-nesses and is currently taking no medications. Social history: Janice lives at home with both parents. Her mother works as a teacher, and her father is a commercial fisherman. The family has a pet cat. Janice's father smokes, but not in the home. Family medical history: Janice's mother (31 years old) and father (30 years old) are healthy and have no history of chronic medical conditions. Her maternal grandmother (age 52 years) has a history of lupus. Her maternal grandfather (54 years of age) has a history of prostate cancer (in remission). Janice's paternal grandfather (age 59 years) has a history of hypertension. Her paternal grandmother (53 years of age) has a history of asthma. Medications: Janice is currently taking no prescription or herbal medications. She has been taking over‐the‐counter pain relievers/antipyretics to relieve symptoms associated with ear pain. Janice Case 3. 1 Earache By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
56 The Toddler/Preschool Child has an allergy to penicillin. She gets hives when she takes penicillin. Janice has no known allergies to food or the environment. She is up to date on required immunizations. OBJECTIVE Janice's vital signs are taken, and her weight in the office today is 14 kg. Her temperature is slightly elevated at 38°C (temporal). Janice is alert and quiet, sitting in her mother's lap. She appears well hydrated and well nourished. Skin: Her skin is clear of lesions and warm to touch. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted. Janice has good skin turgor on examination. HEENT: Janice's head is normocephalic. Her red reflexes are present bilaterally; and her pupils are equal, round, and reactive to light. There is no ocular discharge noted. Janice's external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the right tympanic membrane (TM) is gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the TM. The left TM is erythematous and bulging with purulent fluid visible behind the TM. The TM is opaque with no light reflex or bony landmarks present. Both nostrils are patent. There is no nasal dis-charge, and there is no nasal flaring. Janice's mucous membranes are noted to be moist. She has 20 teeth present without evidence of caries. There are no lesions present in the oral cavity. Neck: Janice's neck is supple and able to move in all directions without resistance. There are shotty anterior cervical nodes present on the left side of the neck. There is no erythema or tenderness of the nodes. Respiratory: Janice's respiratory rate is 26 breaths per minute and her lungs are clear to ausculta-tion in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiovascular: Janice's heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout. Janice's abdomen is soft and non-tender. There is no evidence of hepatosplenomegaly. Genitourinary: Genitourinary examination reveals normal female genitalia. Neuromusculoskeletal: Janice is noted to have good tone in all extremities. She has full range of motion of all extremities. Her extremities are warm and well perfused. Capillary refill is less than 2 seconds, and her spine is straight. CRITICAL THINKING Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for ear pain? What is the most likely differential diagnosis and why?What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 57SUBJECTIVE Four‐year‐old Javier presents to the office with his mother, Carol, with a complaint of bedwetting. Carol states that Javier consistently wets the bed each night although he remains dry throughout the day. According to his mother, Javier has never been dry at night but has been toilet‐trained during the daytime for 2 years. Carol is frustrated with this behavior because she is frequently washing bedsheets and having to buy new mattresses. She has a 5‐year‐old daughter who achieved daytime and nighttime dryness by the age of 3 years old. Carol said that Javier's father is also frustrated with the bedwetting and will sometime spank Javier when he wets the bed. Carol says that her 5‐year‐old daughter teases Javier and calls him names such as “pee‐pee boy. ” She says that she has already tried strategies such as limiting his liquid intake 2 hours before bed and waking him to urinate before she goes to bed. Carol states that often, when she goes to wake Javier before going to bed herself, he has already wet the bed. She does not know what to do now and has come to the office today because she would like assistance in resolving this issue. Javier has no other symptoms of illness. Diet: Javier's nutrition history reveals that he has a balanced diet with enough dairy, protein, fruits, and vegetables. He does not appear to eat or drink large amounts. Elimination: He is voiding well (normal amounts) with no complaints of dysuria. Javier does have occasional constipation that is relieved with an over‐the‐counter laxative. Sleep: Javier sleeps 11 hours at night and has no trouble falling or staying asleep. Past medical history: Born via cesarean section at 38 weeks' gestation. This was a repeat C‐section for Carol. Since being discharged at 4 days of age, Javier has had no hospitalizations. Javier had 4 teeth removed at 2 years of age, under general anesthesia, due to early childhood caries. He had an emergency department (ED) visit at 3 years of age for a broken arm after he fell from the jungle gym at day care. Javier passed his developmental screening at his last well‐child visit. He currently attends preschool and is doing well. He has no chronic illnesses and is taking no medications. Case 3. 2 Bedwetting By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
58 The Toddler/Preschool Child Social history: Javier lives at home with both parents and a 5‐year‐old sibling. His mother works as a store clerk, and his father is a school custodian. The family has no pets. There are no smokers in the home. Family medical history: Javier's mother (26 years old) and father (26 years old) are healthy and have no history of chronic medical conditions. His mother has sickle cell trait. His maternal grand-mother (48 years old) has a history of heart disease. His maternal grandfather (50 years old) has a history of liver disease. Javier's paternal grandfather (51 years old) has a history of vertigo. His paternal grandmother (50 years old) has a history of high cholesterol. Medications: Javier is currently taking no over‐the‐counter, prescription, or herbal medications. He has no known allergies to medication, food, or the environment. He is up to date for required immunizations. OBJECTIVE Javier's vital signs are taken, and his weight in the office is 20 kg. His temperature is within the normal range at 36. 7°C (temporal). When observing Javier's general appearance, he is alert, pleas-ant, and interactive. He appears well hydrated and well nourished. Skin: Javier's skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and Javier has good skin turgor on examination. HEENT: Javier's head is normocephalic. His red reflexes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. Javier's external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Javier's mucous membranes are noted to be moist. He has 16 teeth present. There are no lesions present in the oral cavity. Neck: Javier's neck is supple and able to move in all directions without resistance. There is no cervical lymphadenopathy present. Respiratory: Javier's respiratory rate is 20 breaths per minute, and his lungs are clear to auscul-tation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiovascular: Javier's heart rate is 96 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout, and Javier's abdomen is soft and nontender. Javier has shotty nodes present in his inguinal area bilaterally. These nodes are mobile, nontender, and nonerythematous. There is no evidence of hepatosplenomegaly. Genitourinary: Normal circumcised male genitalia without erythema or lesions. His testes are descended bilaterally. Neuromusculoskeletal: Good tone and full range of motion in all extremities; extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Bedwetting 59 CRITICAL THINKING What laboratory tests or diagnostic imaging studies should be ordered as part of a workup for bedwetting? What is the most likely differential diagnosis and why?What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 61SUBJECTIVE Two‐year‐old Faye presents to the office with her mother, Kellie, with a complaint of a burn to the right hand. Kellie states that she was curling her hair in the bathroom when her telephone rang. She left the bathroom to retrieve the telephone. While she was answering the telephone, Faye entered the bathroom and pulled on the curling iron cord that was hanging down below. The incident was unwitnessed, but Kellie heard Faye scream. She ran to the bathroom to find both Faye and the curling iron on the floor. She then noticed that Faye's right hand was red and swollen. She immediately brought her in to the office. Faye has no symptoms of illness. Diet: Faye's nutrition history reveals that she has a balanced diet with enough dairy, protein, fruits, and vegetables. She has not eaten since she burned her hand. Elimination: She is voiding well with no complaints of dysuria. She is not yet toilet‐trained. Sleep: Faye sleeps 10 hours at night and has no trouble falling or staying asleep. She takes one 2‐hour nap during the day. Past medical history: Faye was born via vaginal delivery at 37 weeks' gestation. Since being dis-charged at 2 days of age, she has had no hospitalizations. She had an emergency department (ED) visit 3 months ago for ingestion of cigarette butts. Faye passed her developmental screening at her last well‐child visit. She currently attends an in‐home day care while her mother is working. Faye has no chronic illnesses and is currently taking no medications. Social history: Faye lives at home with her 18‐year‐old mother, 6‐month‐old sibling, and maternal grandmother. Her father is not involved. Faye's mother works as a nurse's aide in a long‐term care facility. The family has 2 cats. There are no smokers in the home. Family medical history: Faye's mother (18 years old) and father (19 years old) are healthy and have no history of chronic medical conditions. Kellie did have high blood pressure with both pregnancies but the condition resolved after she delivered her children. Her maternal grandmother (age 34 years) has thalassemia trait. Her maternal grandfather (35 years old) is healthy with no chronic illnesses. The health history of Faye's paternal grandfather is unknown. Her paternal grandmother (40 years old) has a history of obesity and high blood pressure. Case 3. 3 Burn By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
62 The Toddler/Preschool Child Medications: Faye is not currently taking any over‐the‐counter, prescription, or herbal medica-tions. She has no known allergies to medication, food, or the environment. She is up to date on required immunizations, although her mother declines the flu vaccine yearly. OBJECTIVE Faye's vital signs are taken, and her weight in the office is 14 kg. Her temperature is within the normal range at 37. 2°C (temporal). She is alert, crying at times, but consolable. She appears well hydrated and well nourished. Skin: The skin on the palm of her right hand is erythematous and beginning to blister. The affected area is painful to touch. The rest of her skin is without lesions. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted, and Faye has good skin turgor on examination. HEENT: Faye's head is normocephalic. Her red reflexes are present bilaterally; and her pupils are equal, round, and reactive to light. There is no ocular discharge noted. Faye's external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally and in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge and no nasal flaring. Faye's mucous membranes are noted to be moist. She has 20 teeth present. There are no lesions present in the oral cavity. Neck: Faye's neck is supple and able to move in all directions without resistance. There is no cervical lymphadenopathy present. Respiratory: Her respiratory rate is 28 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiovascular: Faye's heart rate is 106 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout and Faye's abdomen is soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Normal female genitalia without erythema or lesions. Neuromusculoskeletal: Good tone and full range of motion in all extremities. Her extremities are warm and well perfused. Capillary refill is less than 2 seconds, and her spine is straight. CRITICAL THINKING Are there any laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for a burn? What additional diagnoses should be considered for a pediatric patient with a burn?What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 63SUBJECTIVE Five‐year‐old Lamont presents to the office with his father, Allen, with a complaint of a toothache. Allen states that Lamont woke in the middle of the night, crying, stating that his tooth (on the back, left side of his mouth) hurt. Allen gave Lamont an over‐the‐counter pain reliever to help with the pain. The pain reliever helped, and Lamont went back to sleep. However, when Lamont awakened this morning, he was again complaining of a toothache, and Allen decided to bring him in for a visit. Allen states that he thinks that Lamont had a fever. The family does not have a ther-mometer, but Lamont's forehead felt hot. Lamont has no cough, runny nose, vomiting, or diarrhea. Diet: Lamont's nutrition history reveals that he has a balanced diet with enough dairy, protein, fruits, and vegetables. He also ingests quite a bit of junk food, including chips and cookies. Allen admits that Lamont sometimes drinks juice and soda from a baby bottle. Elimination: Lamont is voiding well with no complaints of dysuria. He has 1 bowel movement daily and denies constipation or diarrhea. Sleep: Lamont sleeps approximately 10 hours at night and has no trouble falling asleep or staying asleep. Past medical history: Lamont was born via vaginal birth in Senegal. His birth was a home birth attended by a local midwife. The exact number of weeks' gestation is unknown, but Lamont's parents state that his was a full‐term birth. Lamont has had no injuries or illnesses requiring visits to the emergency department. He passed his developmental screening at his last well‐child visit. He currently attends kindergarten and is doing well. He has no chronic illnesses and is currently taking no medications. Social history: Lamont lives at home with both parents and his 1‐year‐old sibling. The family has been in the United States for 2 years. They are in the United States so that Lamont's father can study biology at a local university. His mother is currently not working because her visa does not allow her to work. The family has no pets. There are no smokers in the home. Case 3. 4 Toothache By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
64 The Toddler/Preschool Child Family medical history: Lamont's mother (26 years old) and father (30 years old) both have sickle cell trait, but neither has a history of chronic medical conditions. Lamont's 1‐year‐old sister also has sickle cell trait. His maternal grandmother (46 years old) has a history of hepatitis. His maternal grandfather (50 years old) has a history of tuberculosis (successfully treated before Lamont was born). Lamont's paternal grandfather (51 years old) has no known history of health problems. His paternal grandmother (50 years old) has a history of malaria. Medications: Lamont is not currently taking any over‐the‐counter, prescription, or herbal medi-cations. He has no known allergies to medication, food, or the environment. He is up to date on required immunizations. OBJECTIVE Lamont's vital signs are taken, and his weight in the office is 24 kg. His temperature is 37. 5o C (temporal). He is alert, cooperative, and interactive. He appears well hydrated and well nourished. Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There is no dia-phoresis noted, and Lamont has good skin turgor on examination. HEENT: Lamont is normocephalic. Red reflexes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. Lamont's external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Lamont's mucous membranes are noted to be moist when examining his oropharynx. He has 20 teeth present. Both premolars on the lower, left side are noted to have visible caries. The gingival area surrounding those 2 teeth is erythematous and edematous. The area is tender to touch. There are no other lesions present in the oral cavity. Neck: Supple and able to move in all directions without resistance. There is a 1‐cm diameter left, anterior cervical node present. The node is nonerythematous, mobile, and mildly tender to touch. Respiratory: Respiratory rate is 20 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No defor-mities of the thoracic cage are noted. Cardiovascular: Heart rate is 92 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds throughout; soft and nontender. No evidence of hepatosplenomegaly. Genitourinary: Normal uncircumcised male genitalia without erythema or lesions. His testes are descended bilaterally. Neuromuscular: Good tone and full range of motion in all extremities, warm, and well‐perfused. Capillary refill is less than 2 seconds, and his spine is straight. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Toothache 65 CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Complete blood count___Erythrocyte sedimentation test___Dental X‐ray What are the most likely differential diagnoses and why? ___Gingivitis___Dental caries___Periodontitis What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 67SUBJECTIVE Four‐year‐old Jennifer presents to the office with a complaint of abdominal pain for 2 days. She is accompanied by her mother, Anat. Anat states that Jennifer's pain is intermittent and is mainly on the left side of her abdomen. She states that the pain is sometimes worse after eating and that the pain is sometimes relieved by passing gas. Jennifer is unable to describe the quality of the pain, but Anat states that Jennifer will sometimes “double over” in pain. Jennifer has had no vomiting or diarrhea. She has had no cough or runny nose. Diet: Jennifer's nutrition history reveals that she eats bananas and rice almost daily. She drinks 4-5 cups of whole milk daily. Elimination: She is voiding well with no complaints of dysuria. Jennifer has 2-3 bowel movements per week. Anat is unsure of the amount or consistency, since she rarely accompanies Jennifer into the bathroom. Sleep: Jennifer sleeps approximately 10 hours at night. She has no problems falling asleep or staying asleep. Her sleep has not been interrupted by her abdominal pain. Past medical history: Jennifer was born via cesarean section at 37 weeks' gestation. Since being discharged at 4 days of age, she has had no emergency department visits or hospitalizations. Jennifer had bronchiolitis at 6 months of age but has had no injuries or illnesses since that time. Jennifer passed her developmental screening at her last well‐child visit. She currently attends pre-kindergarten and is doing well, according to Anat. She has no chronic illnesses and is not currently taking any medications. Social history: Jennifer lives at home with both parents and a 2‐year‐old sibling. Her mother works as a nurse, and her father is a firefighter. The family has a pet chihuahua. There are no smokers in the home. Family medical history: Jennifer's mother (29 years old) and father (29 years old) are healthy and have no history of chronic medical conditions. Her 2‐year‐old sibling is healthy as well. Her maternal grandmother (52 years old) has a history of Crohn's disease. Her maternal grandfather (54 years old) has a history of asthma. Jennifer's paternal grandfather passed away at 47 years of Case 3. 5 Abdominal Pain By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
68 The Toddler/Preschool Child age from stomach cancer. Her paternal grandmother (53 years old) has a history of obesity and Type 2 diabetes. Medications: Jennifer is currently taking no over‐the‐counter, prescription, or herbal medications. She has no known allergies to medications, food, or the environment. She is up to date on required immunizations. OBJECTIVE Jennifer's vital signs are taken, and her weight in the office today is 27 kg. Her temperature is 37°C (temporal). She is alert, cooperative, and interactive. She appears well hydrated and well nourished. Skin: Her skin is clear of lesions. There is no cyanosis of her skin, lips, or nails. There is no dia-phoresis noted. Jennifer has good skin turgor on examination. HEENT: Jennifer's head is normocephalic. Red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted. Julia's external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally and in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic mem-branes. Both nostrils are patent. There is scant nasal discharge, and there is no nasal flaring. Jennifer's mucous membranes are noted to be moist when examining her oropharynx. She has 20 teeth present without evidence of caries. There are no lesions present in the oral cavity. Neck: Supple and able to move in all directions without resistance; no cervical lymphadenopathy. Respiratory: Respiratory rate is 24 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No defor-mities of the thoracic cage are noted. Cardiovascular: Heart rate is 104 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout; abdomen is soft and mildly tender in the lower left quadrant. There is no evidence of hepatosplenomegaly. Genitourinary: Normal female genitalia. Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities. Extremities are warm and well perfused. Capillary refill is <2 seconds, and spine is straight. CRITICAL THINKING Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for abdominal pain?___Stool test for occult blood___Anorectal manometry___Digital rectal exam___Abdominal radiograph___Blood test for celiac disease | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Abdominal Pain 69 ___Erythrocyte sedimentation rate (ESR) ___Barium enema___Total colonic motility studies___Thyroid function test___Stool culture___Endoscopy/Colonoscopy What is the most likely differential diagnosis and why? ___Functional dyspepsia___Functional constipation___Irritable bowel syndrome___Cyclic vomiting syndrome___Abdominal migraine___Functional abdominal pain syndrome___Gastrointestinal infection___Hirschsprung disease___Intussusception___Celiac disease___Crohn's disease___Dietary intolerances What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. 71SUBJECTIVE Two‐year‐old Lydell presents to the office with his mother and maternal grandmother with a complaint of a r ed area on his penis. Lydell's mother, Stacy, states that when she was changing his diaper 2 days ago, she noticed that Lydell's foreskin was red. She states that she has been putting a diaper rash cream on the area but that it has not helped to relieve the redness. She feels that the area of redness is getting larger and that the area is now painful. Lydell has no fever, cough, runny nose, vomiting, or diarrhea. Diet: Lydell's nutrition history reveals that he has a balanced diet with enough dairy, protein, fruits, and vegetables. His appetite is good and has not changed in the past 2 days. Elimination: Lydell is voiding well, but Stacy thinks that he may have some pain when he uri-nates. She states that diaper changes seem to cause him pain when she cleans the area of redness with the baby wipes. He has 1 bowel movement daily, and Stacy denies that he has constipation or diarrhea. Sleep: Lydell sleeps approximately 11 hours at night and takes one nap daily. He has no trouble falling asleep or staying asleep. Past medical history: Lydell was born at 40 weeks' gestation via vaginal delivery with vacuum assist. Since birth, Lydell has been healthy and has had no injuries or illnesses requiring visits to the emergency department. Lydell passed his developmental screening at his last well‐child visit. He does not currently attend a day care or preschool program. He has no chronic illnesses and is currently taking no medications. Social history: Lydell lives at home with his mother and maternal grandmother. Lydell's father is involved but does not reside in the home. His mother is currently not working outside of the home. The family has a cat. There are no smokers in the home. Family medical history: Lydell's mother (21 years old) has a history of having leukemia as child. She is followed periodically by an oncologist. Lydell's father (23 years old) has a history of asthma. Lydell's maternal grandmother (age 39 years) has a history of multiple sclerosis. His maternal grandfather (40 years old) has a history of Type I diabetes. Lydell's paternal grandfather (41 years Case 3. 6 Lesion on Penis By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
72 The Toddler/Preschool Child old) has no known history of health problems. His paternal grandmother (40 years old) has a history of asthma. Medications: Lydell is not currently taking any over‐the‐counter, prescription, or herbal medications. His mother does apply diaper rash cream to the genital area during diaper changes. Lydell has no known allergies to medication, food, or the environment. He is up to date on required immunizations. OBJECTIVE Lydell's vital signs are taken, and his weight in the office is 17 kg. His temperature is 37. 0°C (temporal). He is alert, playful, and interactive. When crying, he is easily consolable. He appears well hydrated and well nourished. There is no cyanosis of his skin, lips, or nails. There is no dia-phoresis noted, and Lydell has good skin turgor on examination. HEENT: Lydell's head is normocephalic. His red reflexes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. Lydell's external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Lydell's mucous membranes are noted to be moist. He has 18 teeth present. There are no visible caries or other lesions present in the oral cavity. Neck: Lydell's neck is supple and able to move in all directions without resistance. There is no cervical lymphadenopathy noted. Respiratory: Lydell's respiratory rate is 24 breaths per minute, and his lungs are clear to auscul-tation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiovascular: Lydell's heart rate is 96 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout, and Lydell's abdomen is soft and nontender. There is no evidence of hepatosplenomegaly. Genitourinary: Uncircumcised male genitalia with erythema and mild edema on the foreskin. The affected area is mildly tender to touch. A portion of the glans is visible; and there is no discharge, erythema, or swelling noted. His testes are descended bilaterally. There is no erythema or edema of the scrotum. He has shotty lymph nodes present in the inguinal area. Neuromuscular: Good tone and full range of motion in all extremities; extremities are warm and well perfused. Capillary refill is less than 2 seconds, and his spine is straight. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Bacterial culture___Gram stain___Microscopic examination | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Lesion on Penis 73 ___Potassium hydroxide (KOH) ___Urinalysis What is the most likely differential diagnosis and why? ___Balanitis___Phimosis___Paraphimosis___Balanoposthitis What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Section 4 The School‐Aged Child Case 4. 1 Rash without Fever 77 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 2 Rash with Fever 79 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 3 Red Eye 83 By Andrew Konesky, MSN, APRN Case 4. 4 Sore Throat 85 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 5 Disruptive Behavior 89 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 6 Cough and Difficulty Breathing 93 By Nancy Cantey Banasiak, DNP, PPCNP-BC, APRN Case 4. 7 Left Arm Pain 95 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 8 Nightmares 97 By Mikki Meadows-Oliver, Ph D, RN, F AAN Case 4. 9 Gastrointestinal Complaint 101 By Allison Grady, MSN, APNP Case 4. 10 Food Allergies 103 By Allison Grady, MSN, APNP Case 4. 11 Obesity 107 By Mikki Meadows-Oliver, Ph D, RN, F AAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
77 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE A 4‐year‐old female, Abigail, comes to the clinic for evaluation of a rash. She is accompanied to the visit by her mother. According to her mother, Abigail first developed a small, red papule between her nose and her upper lip a few days prior to the appointment today. Her mother thinks that she might have scratched or picked at that area. A few more papules appeared that became fluid‐filled vesicles for a brief amount of time. The fragile roofs of these vesicles quickly sloughed off. The newly eroded skin developed overlying honey‐colored crusts. The patient complains that the rash is sometimes pruritic, so she has been scratching the area. Abigail's mother feels that the rash is spreading due to Abigail's manipulation of the area. Abigail has been afebrile and has maintained a normal appetite and activity level by report. Diet: Adequate and varied. Elimination: Voids every 3-4 hours. Normal bowel movements daily. Past medical history: Abigail is a healthy 4‐year‐old with no significant medical history. She does not have any chronic medical problems and has not had surgery. Family history: One of Abigail's cousins has a similar rash on her arm. Otherwise noncontributory. Social history: Abigail and her mother live in a 4‐bedroom duplex with her 2 siblings, a grand-mother, a grandfather, an aunt, an uncle, and 3 cousins. There are no pets in the home. Abigail's mother works part‐time doing housekeeping for a nearby hotel. She reports that she earns minimum wage. Abigail's father has not been in contact with the family since before she was born. Medications: Abigail does not take any medications regularly. Her mother has not given her any oral medications to treat this problem. Her mother did apply some over‐the‐counter 1% hydro-cortisone cream to the area but does not feel that it helped. Allergies: Abigail is not allergic to any medications. There are no suspected allergies to soaps, detergents, foods, or other environmental factors. Case 4. 1 Rash without Fever By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
78 The School-Aged Child OBJECTIVE General: Alert, well‐nourished female in no apparent distress. She appears nontoxic and is col-oring pictures calmly during the exam. Vital signs: Heart rate: 96; respiratory rate: 16; temperature: 98. 8°F; height: 40 inches; weight: 42 lbs (19 kg). HEENT: Moist mucous membranes without ulcerations; nares patent bilaterally without drainage. Conjunctivae clear without erythema or discharge. Lymphatic: No cervical, supraclavicular, or occipital lymphadenopathy. Cardiovascular: Regular heart rate and rhythm; no murmur. Respiratory: Regular respiratory rate with clear and equal air movement bilaterally. Skin: Mildly erythematous, confluent plaque of eroded skin inferior to nares and superior to upper lip. Honey‐colored crusts overlying the affected area. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Bacterial culture___Bacterial culture of the nares___Examination of Tzanck smear___Fluorescent antibody testing of smears___Fungal culture___Gram stain___Potassium hydroxide (KOH) examination___Viral culture What is the most likely differential diagnosis and why? ___Atopic dermatitis___Herpes simplex virus (HSV)___Impetigo What is the treatment plan?What would the appropriate treatment plan for this diagnosis be if the patient were febrile and/ or showing other signs of systemic illness? What is the plan for follow‐up care?Are any referrals needed?Should the patient stay out of school and/or day care during treatment? If so, for how long?What, if anything, should be recommended to unaffected household members? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
79 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Seven‐year‐old Aubrey presents to the office with a complaint of a rash for 2 days. She is accom-panied by her mother, Jessica. Aubrey has also had a mildly runny nose and cough for 3 days. She has had a low‐grade fever, and her maximum temperature at home was 37. 9°C (oral). Aubrey has had no vomiting or diarrhea. Diet: Normally has a balanced diet with enough dairy, protein, fruits, and vegetables. There has been no change in appetite since her symptoms began. Elimination: Voiding well with no complaints of dysuria. Sleep: Sleeps approximately 9 hours at night and has no problems falling asleep or staying asleep. Past medical history: Aubrey was born via cesarean section at 38 weeks' gestation for a breech presentation. Since being discharged home at 4 days of age, she has had no hospitalizations. Aubrey had an emergency department visit at 5 years of age for sutures to her head after she fell and struck her head on the corner of a table. She has had no injuries or illnesses since that time Family history: Aubrey's mother (34 years old) has a history of migraine headaches. Her father (30 years old) is healthy and has no history of chronic medical conditions. Her 5‐year‐old sibling has Type 1 diabetes. Her maternal grandmother (68 years old) has Type 2 diabetes. Her maternal grandfather (68 years old) has a history of chronic obstructive pulmonary disease (COPD). Aubrey's paternal grandfather (58 years old) has a history of skin cancer. Her paternal grandmother (53 years old) has hypertension. Social history: Aubrey currently attends elementary school. She is in the second grade and is doing well, according to her mother. Aubrey lives at home with her parents and her 5‐year‐old sibling. Her father is a graduate student, and her mother is an accountant. The family has a pet rabbit. Medications: Aubrey is not currently taking any over‐the‐counter, prescription, or herbal medi-cations. Aubrey has no known allergies to food, medications, or the environment. At her last well‐child check, her mother refused the annual flu shot and the second varicella vaccination because Aubrey had a cold. The family did not return to the office to receive these 2 vaccines. Case 4. 2 Rash with Fever By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
80 The School-Aged Child OBJECTIVE General: Aubrey is alert, active, and cooperative. She appears well hydrated and well nourished. Vital signs: Weight in the office today is 33 kg. Her temperature is slightly elevated at 37. 9° Celsius (oral). Skin: A predominantly maculopapular rash is noted on her back and chest. Two vesicles are noted on the upper right side of her chest. There is no rash noted elsewhere in her body. There is no cyanosis of her skin, lips, or nails. There is no diaphoresis noted. Skin has elastic recoil. HEENT: Normocephalic; red reflexes are present bilaterally; and her pupils were equal, round, and reactive to light. There is no ocular discharge noted. Aubrey's external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic exam-ination, both tympanic membranes are gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Aubrey's mucous membranes are noted to be moist when examining her oropharynx. There is no inflammation of her tonsils, and there are no oral lesions noted. Neck: Supple and able to move in all directions without resistance. There is no cervical lymph-adenopathy noted. Respiratory: Rate is 20 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiac: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. No evidence of hepatosplenomegaly. Genitourinary: Normal prepubertal female genitalia. Neuromusculoskeletal: Good tone and full range of motion of all extremities; extremities are warm and well perfused. Capillary refill is less than 2 seconds. Spine is straight. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Tzanck smear___Viral culture___Direct fluorescent antigen testing___Varicella polymerase chain reaction___Potassium hydroxide (KOH) smear___Throat culture for group A beta‐hemolytic streptococci (GABHS)___Nasal swab for influenza | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Rash with Fever 81 What is the most likely differential diagnosis and why? ___Varicella zoster virus (breakthrough)___Herpes zoster___Scarlet fever___Viral exanthem___Lyme disease___Tinea corporis What is the plan of treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
83 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Will, a 12‐year‐old male, was referred to the school‐based health center (SBHC) at the request of his mother for a red right eye, noticed this morning upon awakening. Will reports waking up this morning with his right eyelid “stuck together like glue. ” He reports washing his face and eyes with warm water, allowing him to open his eye. He noticed his eye was “a little red,” but did not report any pain or itch. He has had to wipe his eye a few times since washing his face, as “yellow stuff keeps coming out. ” Will reports wearing glasses daily and has never worn contact lenses. He is experiencing no visual disturbances and denies blurriness and double vision. Will's mother was contacted by the SBHC to provide confirmation of history and further details. His mother denies sick contacts at home, but Will's cousin, whose house he slept at over the weekend, was given “eye drops” last week by his primary care provider. Birth history: Will was born full term. His birth weight was 8 lbs 5 oz and birth length was 20 in. Past medical history: Will has seasonal allergies, which are exacerbated every fall, that are well con-trolled on daily allergy medication. He has myopia and has been wearing glasses since age 6. He had an appendectomy 2 years ago when he was 10 years old. He has multiple visits to the SBHC for acute, unrelated presentations. He has no further significant history, hospitalizations, or surgeries. Social history: Will lives with his mother, father, and older sister in a single‐family house. Will is in the seventh grade and plays on the school lacrosse team. He wants to one day be a professional lacrosse player. He is also the team manager for the town's local hockey team, and enjoys art and music in his spare time. Will has multiple friends at school and a few close friendships. Diet: Will eats 3 meals a day and reports a normal appetite. He consumes a varied diet of fruits, vegetables, dairy products, and protein sources. Elimination: Denies difficulty going to the bathroom. Reports regular bowel patterns. Sleep: Sleeps an average of 8 hours per night. Denies nighttime awakenings, snoring, and restlessness. Family medical history: Will's family history is positive for heart disease on his father's side; his father had a myocardial infarction several years ago. His father may have high blood pressure, Case 4. 3 Red Eye By Andrew Konesky, MSN, APRN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
84 The School-Aged Child but he is not sure. Will denies family history of cancer and or diabetes. His paternal and maternal grandparents are alive and well. He is unsure of his grandparent's medical history. Medications: 10 mg Zyrtec daily, Naphcon allergy eye drops as needed, daily multivitamin. Allergies: Seasonal. No medication allergies reported. No food allergies reported. OBJECTIVE General: Male presenting in no acute distress, well hydrated, conversational and appropriate with provider. Vital signs: Height: 68 in; weight: 135 lbs; BMI: 20. 5; BP: 116/70; HR: 75; RR: 16. Skin: Skin is clear with no rashes noted. Small scar is noted at right lower abdominal quadrant s/p appendectomy. Skin is warm and dry. HEENT: On examination, right eye is mildly injected, with thick, yellow discharge draining from inner canthus. Dried, yellow crusting is noted across lower lid. Upon cleansing the canthus, discharge r eappears spontaneously throughout duration of exam. Pupils are equal and round, reactive to light, with accommodation showing normal pupillary reflex. Visual acuity is 20/20 on Snellen test with corrective lenses. Red reflex is noted and optic discs are without hemorrhage. Head is normocephalic and atraumatic. Tympanic membranes are clear, intact, with landmarks and cone of light visualized, bilaterally. Nasal turbinates are pale, swollen, and with mild clear discharge. Nasal septum is vertically aligned with no report of pain or discomfort upon palpation of frontal and maxillary sinuses. Oral pharynx is clear with no erythema noted. Tonsils +2 of 4 with no exudate or erythema. Posterior pharynx has minimal post nasal drainage and mild cobbling. Neck: Supple with full range of motion in all directions. No cervical lymphadenopathy. Cardiovascular: Regular rate and rhythm. S1/S2 auscultated with no murmur, clicks, rubs, gallops. Equal +2 carotid and radial pulse bilaterally. Respiratory: Clear to auscultation. No wheezes, rhonchi, rales noted. Good air exchange. Abdomen: Soft, nontender, nondistended, normal active bowel sounds in all 4 quadrants. Genitourinary: Deferred. Neurologic: Alert and oriented. Cranial nerves grossly intact. Good eye contact. Gait normal. Uvula rises midline and symmetrically. CRITICAL THINKING What are the top three differential diagnoses in this case and why? What are the diagnostic tests required in this case and why?What is the plan of treatment?Are there any standardized guidelines that should be used to treat this case? If so, what are they?What are the plans for follow‐up care and referral?Are there any special examination and or treatment considerations that may affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
85 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Eight‐year‐old Suzanna presents to the office with a complaint of a sore throat for 2 days. She is accompanied by her mother, Mikayla. Suzanna has had an intermittent fever and her maximum temperature at home was 101°F (oral). Suzanna complains that she has pain when she swallows. She also complains of a headache. Both the throat pain and headache are relieved slightly with the use of over‐the‐counter pain relievers. Suzanna has had no vomiting or diarrhea. She has had no runny nose or cough. She denies drooling or difficulty breathing. Diet: Suzanna's nutrition history reveals that she normally has a balanced diet with enough dairy, protein, fruits, and vegetables. Her appetite has decreased over the past 2 days since the throat pain began. Elimination: She is voiding well with no complaints of dysuria. Sleep: Suzanna usually sleeps approximately 9 hours at night. She usually has no problems falling or staying asleep but since the throat pain has started, her sleep has been interrupted. Past medical history: Suzanna was born via vaginal delivery at 38 weeks' gestation. Since being discharged at 2 days of age, she has had no hospitalizations. Suzanna had an emergency department visit at 4 years of age for a broken clavicle that she sustained after falling from the jungle gym at preschool. She has had no injuries or illnesses since that time. Family history: Suzanna's mother (28 years old) has a history of hyperthyroidism. Her father (30 years old) is healthy and has no history of chronic medical conditions. Her maternal grand-mother (56 years old) has emphysema. Her maternal grandfather (57 years old) has a history of asthma. Suzanna's paternal grandfather (58 years old) has a history of hypertension. Her paternal grandmother (53 years old) has multiple sclerosis. Social history: Suzanna currently attends elementary school. She is in the third grade and is doing well, according to Mikayla. Suzanna lives at home with her mother, who works as an office manager, and her father, Joe, who is a professional carpenter. The family has a pet fish. Suzanna attends an after‐school program. Case 4. 4 Sore Throat By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
86 The School-Aged Child Medications: Suzanna is currently taking no prescription or herbal medications. She has been taking over‐the‐counter pain relievers/antipyretics to relieve symptoms associated with her throat pain. Allergies: Suzanna has no known allergies to food, medications, or the environment. She is up to date on required immunizations. OBJECTIVE General: Alert, quiet, and cooperative; appears well hydrated and well nourished. Vital signs: Weight in the office today is 36 kg; temperature is slightly elevated at 38. 4°C (oral). Skin: Clear of lesions and warm to touch. There was no cyanosis of her skin, lips, or nails. There was no diaphoresis noted; skin with elastic recoil. HEENT: Normocephalic; red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted. External ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, both tympanic membranes are gray, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge and no nasal flaring. Samantha's mucous membranes are noted to be moist when examining her oropharynx. Both tonsils are erythematous and inflamed. There are exudates present bilaterally, as well as palatal petechiae. Neck: Supple and able to move in all directions without resistance; tender anterior cervical nodes present on both sides of the neck; no erythema of the nodes. Respiratory: Respiratory rate was 28 breaths per minute, and her lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiac: Heart rate was 112 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds were present throughout; soft and nontender; no evidence of hepatosplenomegaly. Genitourinary: Normal prepubertal female genitalia. Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities; extremities warm and well‐perfused. Capillary refill is less than 2 seconds. Her spine is straight. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Throat culture___Rapid strep test___Complete blood count (CBC)___Monospot___Liver function tests (LFTs) | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Sore Throat 87 What is the most likely differential diagnosis and why? ___Viral pharyngitis___Bacterial pharyngitis___Fungal pharyngitis___Peritonsillar abscess___Group A beta‐hemolytic streptococci (GABHS) What is the plan for treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
89 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE This mother presents with 6‐year‐old Jason with concerns about his increasingly disruptive behavior at home. She reports that Jason has always been a difficult child to manage, often is irritable, angers easily, and resists any changes in routine. He argues constantly with his 8‐year‐old sister about simple activities. He grabs her toys, interferes with her play, and has begun to be more physically aggressive with her. Jason argues with his mother and grandmother when any limits are put on his behavior. He is uncooperative regarding the simplest of requests like coming to the table for meals, turning off his video games, or staying in the yard. Jason has had a few good relationships with children in the neighborhood. His mother has attempted to discipline Jason through a variety of methods, such as talking, screaming, time out, losing TV and video game time, and occasional spankings. His mother reports that no methods work. She is exhausted by the attention she spends on his behavior and is frustrated facing discipline issues every day from breakfast to bedtime. She is confused because her daughter has never demonstrated these types of issues, and she used basically the same parenting strategies with her daughter as she did with Jason. His mother has not spoken with Jason's first‐grade teacher to see if similar behaviors are occurring in school. Diet: Jason has been a healthy child. He had some initial feeding issues as an infant with excessive irritability causing multiple formula changes. Since then he has had no food allergies or intoler-ances and eats a fairly well‐balanced diet with the exception of excessive juice consumption. Elimination: No difficulties. Sleep: Jason has had difficulty establishing nighttime sleep patterns. He continues to have diffi-culty with sleep onset, wakes frequently, and goes into his mother's bed. Past medical history: Jason was the second child born to a 27‐year‐old mother by vaginal delivery after an uneventful full‐term pregnancy. He weighed 7 lbs 9 oz and had no problems in the newborn nursery (no temperature instability, no jaundice, and no respiratory issues). He was discharged home with his mother on cow's‐milk formula at 48 hours of age. Jason experienced a head injury with a loss of consciousness at the age of 3 years. His head CT was normal, but he was admitted to the pediatric unit for overnight observation. He has not had any obvious sequelae from this incident. Jason has had no respiratory, cardiac, neurologic, or allergic problems. Case 4. 5 Disruptive Behavior By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
90 The School-Aged Child Family history: Jason's mother has history of Hashimoto thyroiditis and depression and is med-icated for both of these conditions. She is fairly adherent to her medication regime. She was an average student, graduated from high school, and works as a cashier. Jason's 33‐year‐old father has a history of substance abuse, depression, and hypertension. He was incarcerated briefly for selling drugs and now declines all medications. He did not complete high school, has a history of delinquency and attention problems, and currently works intermittently in construction. The maternal grandparents both have well‐controlled hypertension and hypercholesterolemia. The paternal grandparents' histories are unknown to the father since he has not had contact with them in 15 years. Jason's sister is healthy and doing average schoolwork. Social history: Jason's mom is single and lives on the second floor of a 1940s 2‐family house with the maternal grandparents on the first floor. Jason's household consists of his mother, an 8‐year‐old sister, 2 dogs, and several cats. His mother and the children have frequent contact with the father, but he is not a regular part of the household. Both parents smoke while with the children. Jason attended day care full‐time until school entry but now returns home to the care of his grandparents after school. Toward the end of his time in day care, his mom reports that she had received a few calls about Jason's behavior, specifically some difficulties participating in group activities and following directions. Medications: Takes no medications. OBJECTIVE General: Alert, active, responsive to most requests with good articulation, some fidgeting with instruments. Vital signs: Height: 46 inches (115 cm); weight: 45 lbs (20. 9 kg); heart rate: 92; respiratory rate: 18; blood pressure: 98/62. HEENT: Normocephalic; PERRL full EOMs, normal convergence, normal discs; gray TMs with good light reflexes and landmarks. Nose is normal, midline septum, boggy turbinates. Throat reveals large tonsils, no erythema, and uvula midline. Neck: Supple; full range of motion; thyroid not palpable; no lymphadenopathy. Cardiac: Regular rate and rhythm; S1/S2; no murmur; pulses full and equal. Respiratory: Clear breath sounds throughout. Abdomen: Soft, no mass, no hepatosplenomegaly. Genitourinary: Normal male, circumcised, testes descended ×2. Musculoskeletal: Full range of motion for all extremities; symmetric movement. Neurologic: Normal tone, strength, coordination, reflexes and cranial nerves II‐XII grossly intact. Skin: Clear, dry patches on elbows and knees. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___CBC___Thyroid studies | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Disruptive Behavior 91 ___Lead screening ___Vision screening___Hearing screening___Vanderbilt ADHD screening for school and parent___Learning disability evaluation___Pediatric Symptom Checklist What is the most likely differential diagnosis and why? ___Normal active behavior of early childhood___Hearing impairment___Attention‐deficit hyperactive disorder (ADHD)___Learning disability___Oppositional defiant disorder (ODD)___Conduct disorder___Depression What is the plan of treatment?What is the plan for follow‐up care?Are there any demographic factors that might affect this case? NOTE: The author would like to acknowledge Patricia Ryan‐Krause, MSN, APRN, who co‐authored this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
93 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Emily is a 6‐year‐old female who presents to the clinic with her mother. She presents with com-plaints of cough and difficulty breathing. Two days prior, Emily developed a nonproductive cough that is worse at night, clear rhinorrhea, and a fever with a maximum temperature of 102°F. The mother has treated the fever with Tylenol 320 mg every 4 hours, as needed, when the temperature was greater than 101°F. Her mother also complains that “when she gets a cold, it lasts longer than normal. ” Birth history: Emily was born full term weighing 3200 g by normal spontaneous vaginal delivery (NSVD). Pregnancy and delivery were uncomplicated with Apgar scores of 8 (1 minute) and 9 (5 minutes). Social history: Emily is a 6‐year‐old female in the first grade who lives with her mom, dad, and 2 siblings in a house in the city. They have 4 pets: 2 dogs, 1 cat, and 1 turtle. The parents work outside the home and have private health insurance. Emily and her siblings attend an after‐school program until her mom picks them up after work. Emily attends regular medical and dental appointments, and they deny tobacco or alcohol use in the home. She plays soccer, ice hockey, and lacrosse. Diet: Emily's appetite is fair with a fluid intake of 32 oz/day of juice/milk/water. She also reports normal eating habits without abdominal pain or diarrhea. Elimination: Emily voided 4 times yesterday. No vomiting or diarrhea. Her mother complains that everyone in the house is sick with the same symptoms. Sleep: Emily sleeps from 8 p. m. to 6 a. m. She coughs 1-2 times during the night. Past medical history: Past medical history is positive for obstructive sleep apnea 4. Birth history was uneventful. Emily also has a history of bronchiolitis at 8 months of age, which did not require medication or hospitalization. Family history: Mother (age 36): healthy, atopic dermatitis, seasonal allergies; father (age 35): healthy, asthma, seasonal allergies; sibling (age 4): healthy; sibling (age 2): healthy; maternal grandmother (age 80): hypertension, breast cancer, basal cell skin cancer; maternal grandfather Case 4. 6 Cough and Difficulty Breathing By Nancy Cantey Banasiak, DNP, PPCNP‐BC, APRN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
94 The School-Aged Child (age 81): hypertension, diabetes mellitus Type 2; paternal grandmother (age 76): hypertension, obesity; paternal grandfather (age 72): deceased, hypertension, stroke. Medications: Emily is currently on no medications. Immunizations are up to date. Allergies: Has no known allergies to medications, food, or the environment. OBJECTIVE General: Emily is alert, well hydrated, active, and cooperative. Vital signs: Temperature 38°C, pulse 72, and respirations 28 per minute with a blood pressure of 100/52 in the left arm. The O2 saturation is 94%, and weight is 25 kg. Skin: No lesions, rashes, or scars; and the patient is not cyanotic. HEENT: Normocephalic with no evidence of trauma or lesions. Eyes show no signs of drainage; sclera white, with pink conjunctiva. Otoscopic examination reveals tympanic membranes gray bilaterally with positive light reflex and normal pinnae. The nose has clear rhinorrhea; no nasal polyps with pink turbinates. Examination of the throat shows a cobblestone appearance in the posterior pharynx, uvula midline, tonsils size 0/4 with no exudate or erythema, moist mucous membranes; and the trachea is midline. Respiratory: Bilateral inspiratory and expiratory wheezing; mild intercostal retractions; mild shortness of breath; no rales, crackles, or nasal flaring. Cardiovascular: No murmur; normal S1/S2; 2+ brachial and femoral pulses; no cyanosis, clubbing, or edema noted. Lymphatic: There is no lymphadenopathy on examination. Abdomen: Soft, nontender, nondistended; + bowel sounds; no hepatosplenomegaly during palpation. Genitourinary: Normal female genitalia. Neurological: Grossly intact. CRITICAL THINKING What diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Oxygen saturation___Chest X‐ray___Nasal pharyngeal swab for direct fluorescent antibody (DFA) What are the top differential diagnoses and why?What is the most likely differential diagnosis and why?What is the plan of treatment?What is the plan for follow‐up care?Are any referrals needed at this time?Are there any standardized guidelines that should be used to assess or treat this case? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
95 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Jair, a 11‐month‐old infant, presents to the primary care office with a complaint of not using his left arm for one day. He is accompanied by his parents. His father states that Jair fell off the couch yesterday and he thinks that Jair may have landed on his left arm. The history provided by his mother is somewhat different. She states that Jair fell down two stairs while in a walker and hurt his left arm at that time. Birth history: Jair was born at 35 weeks' gestation. His birth weight was 2200 g. There were no complications during the labor or delivery. The mother had no infections, falls, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. Jair was discharged after 4 weeks in the neonatal intensive care unit to home with his mother. The social history reveals that Jair was born to a adolescent single mother. His father, 18 years old, is involved but does not reside in the household. Jair lives in an apartment with his mother and 19‐year‐old cousin. The maternal grandmother (MGM) lives in the neighborhood and is able to help Jair's mother with child care. The family receives assistance from governmental subsidies such as the Women, Infants, and Children (WIC) supplemental nutrition program, Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, both Jair's mother and father have high school diplomas. She works at a fast‐food restaurant. Joseph's father works as a construction worker. The family has no pets. There are no smokers in the home. Diet: Jair eats a balanced diet of table foods. He is transitioning from formula to whole milk. He takes a daily multivitamin. Elimination: 4-6 wet diapers daily with 1 bowel movement. Sleep: Takes one 2‐hour nap daily and sleeps 12 hours at night. Family medical history: Paternal grandfather (age 54): healthy; paternal grandmother (age 53): hypertension; maternal grandfather (age 46): hypothyroidism; MGM (age 44): Type 2 diabetes; mother (age 18): asthma; father (age 18): healthy. Medications: Currently taking no prescription, herbal, or over‐the‐counter medications. Immunizations: Up to date. Allergies: No known allergies to food, medications, or environment. Case 4. 7 Left Arm Pain By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
96 The School-Aged Child OBJECTIVE Vital signs: Weight: 10 kg; length: 84 cm; temperature: 37°C (axillary). General: Alert; well nourished; well hydrated; interactive. Skin: Right side of forehead with ecchymosis and a 2 cm abrasion; no other lesions noted. No cyanosis of lips, nails, or skin; no diaphoresis noted; good skin turgor. Head: Normocephalic; anterior fontanel is open and flat (1 cm × 1 cm). Eyes: Red reflexes present bilaterally; pupils equal, round, and reactive to light; no discharge noted. Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex. Nose: Both nostrils are patent; no discharge. Oropharynx: Mucous membranes are moist; 4 teeth are present; no lesions. Neck: Supple; no nodes. Respiratory: RR = 24; clear in all lobes; no adventitious sounds noted; no retractions; no defor-mities of the thoracic cage noted. Cardiac/Peripheral vascular: HR = 100; regular rhythm. No murmur noted. Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly. Genitourinary: Normal circumcised male genitalia; testes descended bilaterally. Back: Spine straight. Ext/Musculoskeletal: Left arm with limited range of motion and tenderness to touch over left clav-icle and left humerus. Both tender areas are slightly swollen and erythematous. Full range of motion of all other extremities; warm and well perfused; capillary refill < 3 seconds in all extremities. Neurologic: Good strength and tone. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Radiograph of left arm/clavicle___CBC___Metabolic panel What is the most likely differential diagnosis and why? ___Fracture of left arm/clavicle to accidental fall___Physical abuse___Osteogenesis imperfecta What is the plan for treatment, referral, and follow‐up care?Are there any referrals needed?Does the patient's psychosocial history impact how you might treat him? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
97 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Six‐year‐old Daniel presents to the office with his mother, Donna, with complaints of frequent night-mares. Donna states that Daniel will be asleep and will suddenly sit upright with his eyes open and start to scream loudly. She says that Daniel looks terrified and that he sweats and breathes fast during these episodes. Donna says that while Daniel is screaming, she is unable to wake, console, or comfort him. The screaming episodes typically last about 5 minutes each and happen 3-4 times weekly. Donna states that after the screaming stops, Daniel returns to sleep and does not remember the screaming episodes when he awakens in the morning. Daniel does not have any problems falling asleep. He sleeps approximately 10 hours each night but does not have a set bedtime or a regular bedtime routine. He sleeps in his own bed and shares a room with his younger brother. Diet: Balanced diet with sufficient sources of dairy, protein, fruits, and vegetables. Elimination: Daniel is voiding well with no complaints of dysuria. He has 1 bowel movement daily and denies constipation or diarrhea. Past medical history: Born via vaginal birth at 40 weeks' gestation. The mother's pregnancy was without problems. She had no infections, falls, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. There were no problems for Daniel during his neonatal period. Since birth, he has had no injuries or illnesses requiring visits to the emergency department. He has no chronic illnesses. Family history: Daniel's mother (27 years old) and father (26 years old) are both healthy and have no history of chronic medical conditions. His 3‐year‐old sibling also has no history of chronic medical conditions. His maternal grandmother (54 years old) has a history of asthma. His maternal grandfather (55 years old) has a history of high cholesterol. Daniel's paternal grandmother (52 years old) has a history of hypertension. His paternal grandfather (52 years old) has a history of hyper-tension and had a stroke at age 47 years. Social history: Daniel lives at home with his mother, paternal grandmother, paternal uncle, and his younger brother (3 years old). His mother works as a restaurant waitress. Daniel's father is incarcerated. The family has no pets. There are no smokers in the home. Case 4. 8 Nightmares By Mikki Meadows‐Oliver, Ph D, RN, FAAN | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
98 The School-Aged Child Medications: Daniel is not currently taking any over‐the‐counter, prescription, or herbal medica-tions. He has no known allergies to medication, food, or the environment. He is up to date for required immunizations. OBJECTIVE General: Alert, cooperative, and active; appears well hydrated and well nourished. Vital signs: Weight in the office was 28 kg. Temperature was 36. 9°C (temporal). HEENT: Normocephalic. Red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted; external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge and no nasal flaring. Daniel's mucous membranes were noted to be moist when examining his oropharynx. There is no evidence of visible caries or other lesions in the oral cavity. Neck: Supple and able to move in all directions without resistance. There was no cervical lymph-adenopathy present. Skin: Clear of lesions; no cyanosis of his skin, lips, or nails; no diaphoresis noted; and there is elastic recoil. Respiratory: Respiratory rate is 20 breaths per minute, and the lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted. Cardiac: Heart rate is 102 beats per minute with a regular rhythm. There is no murmur noted upon auscultation. Abdomen: Normoactive bowel sounds are present throughout. Soft and nontender. No evidence of hepatosplenomegaly. Genitourinary: Normal circumcised male genitalia without erythema or lesions; testes are descended bilaterally. Neuromusculoskeletal: Good tone and full range of motion in all extremities. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. Spine is straight. CRITICAL THINKING Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___EEG (electroencephalogram)___Polysomnography___MRI (magnetic resonance imaging)___CT (computed tomography) scan___Skull radiograph | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
Nightmares 99 What is the most likely differential diagnosis and why? ___Nightmares___Nocturnal seizures___Night terrors___Sleepwalking (somnambulism) What is the plan for treatment, referral, and follow‐up care?Does this patient's psychosocial history affect how you might treat this case?What if the patient lived in a rural setting?Are there any demographic characteristics that might affect this case? NOTE: The author would like to acknowledge the contribution of Allison Grady, MSN, RN to this case in the first edition of this book. | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
101 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. SUBJECTIVE Seven‐year‐old Katie presents with new onset gastrointestinal complaints. She has no significant past medical history and no known allergies. She was recently seen in her primary care provider's office for a well‐child check. It was noted that her growth curve had plateaued for the past 2 years and she is now “falling off” her curve. Her mother describes Katie as a “classic picky eating toddler” who, in the past 2 years, has begun expanding list of acceptable foods. In the past several months, the mother has noticed that Katie has had increased incidences of diarrhea and abdominal pain. It has interfered in her ability to attend school and she is missing approximately 3 days per month due to symptoms. Her diarrhea is not accompanied by fever, upper respiratory infection (URI) symptoms, or vomiting. No one else in the house has experienced similar complaints. Birth history: Katie was born at 38 weeks' gestation via spontaneous vaginal delivery. She weighed 7 lbs, 7 oz and required no NICU placement. Social history: Katie is in second grade and lives with her mother and father. Katie does well in school and is easily able to name friends and her favorite subject. Katie has a 5‐year‐old sister, Madison. The family owns their own home in a suburb. They have 2 dogs. Diet: Katie is described as a “reformed picky eater” by her mother. She eats steak and chicken for meat (refuses fish); flavored yogurt and cheese are her main sources of calcium; her favorite foods are turkey sandwiches, goldfish crackers, and pasta. Katie does not drink juice or soda. She has 3-5 servings of fruits or vegetables per day. Elimination: Stools daily and these are described as soft and non‐painful to pass. As noted by her mother, Katie has been experiencing greater frequency of diarrhea (1-3 times per week) which her mother describes as frequent, very loose, and malodorous. Katie urinates several times per day and denies any pain with urination. She has no history of urinary tract infection (UTI). Sleep: Katie goes to bed at 8 p. m. and wakes up between 6:30 and 7 a. m. She generally sleeps through the night and sleeps alone in her own bed. Her mother reports that Katie has occasionally awakened during the night to stool. Family history: Katie's mother reports a history of multiple miscarriages, and her father has a history of high cholesterol (on medication). Her maternal aunt has a history of celiac disease. Her Case 4. 9 Gastrointestinal Complaint By Allison Grady, MSN, APNP | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
102 The School-Aged Child maternal grandmother has a history of colorectal cancer (deceased). Her paternal grandfather has Type 1 diabetes. Medications: Katie takes a multivitamin daily. Allergies: Katie has no known allergies. OBJECTIVE General: Katie is a 7‐year‐old feminine appearing child who presents in no acute distress. She is interactive and age‐appropriate in her responses. Vital signs: Heart rate is 90; respiratory rate is 14; blood pressure is 95/55, oxygen saturation is 100% on room air; pain is rated as a 0. HEENT: Normocephalic; thick brown hair; eyes slightly sunken; tympanic membranes visible and with no evidence of effusion/infection; nostrils patent; trachea is midline. There is no evidence of enlarged thyroid. Mouth: Mucous membranes with thick saliva. Mild enamel erosion on teeth. Dentition reveals mix of primary and secondary teeth. Cardiac: Heart with regular rate and rhythm. There is no murmur noted. Respiratory: Lungs are clear to auscultation bilaterally. There is equal air movement in all lobes. Abdomen: Abdomen is soft, mildly tender to palpation. There is intermittent guarding in the right upper quadrant. Normoactive bowel sounds are present throughout. There are no masses or hepa-tosplenomegaly appreciated. Genitourinary: Tanner stage 2 external female genitalia. There are no anal or rectal fissures, tags, or hemorrhoids. Neuromusculoskeletal: Moves all 4 extremities equally with appropriate strength. Neurologic: Alert and oriented to person, place, time, situation. Cranial nerves are grossly intact. Psychological: Not visibly anxious or agitated. CRITICAL THINKING What are the three most likely differential diagnoses for this patient? What tests would help to confirm your suspicions? What other information gathered through noninvasive methods would help to confirm the diagnosis? What information from the family history helps to guide your differentials?Once the diagnosis is established, what other multidisciplinary support would you offer the patient and family? What other medical specialties/subspecialties would you engage? | Leslie Neal-Boylan - The Family Nurse Practitioner.pdf |
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