Assignment:Jonathan Reyes Management Plan Paper
Assignment:Jonathan Reyes Management Plan Paper
Assignment:Jonathan Reyes Management Plan Paper
Management Plan
The management plan is for a two-year-old patient. A 2-year-old male presents to the office with his mother for a dry cough and runny nose, which started two days ago. The mother reports the patient has a fever that started yesterday; the highest temperature reported by the patient’s mother is 101.0 F. He is currently taking Tylenol for fever. The mother states it gives the patient relief and returns in 4 hours. The patient’s immunizations are up to date, but he has not received the flu shot this year due to getting sick from last year’s flu shot. The patient’s mother states his appetite has decreased since being sick. He attends daycare with several children who are sick. The mother denies any rash, nausea, vomiting, discharge from the ear, or pulling ears.
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Primary Diagnosis: Otitis Media (ICD 10 code: H66.9)
The primary diagnosis based on the symptoms displayed by the patient is Otitis Media. This is an infection of the middle ear that causes inflammation (Swelling and redness) and a build-up of fluid behind the eardrum. Even though anyone can develop the condition, it is more common among infants between six and fifteen months old. The most common symptoms of otitis media include slight hearing loss in the event the middle ear becomes filled with fluid, a lack of energy, being sick, high temperature (fever), and earache (Venekamp et al.,2020). Young children may have various symptoms, such as loss of balance, being unresponsive to quiet sounds or inattentiveness, runny nose or coughing, irritability, restlessness, and poor feeding. Other symptoms include a raised temperature and rubbing, tugging, and pulling of the air. The patient shows a host of these symptoms making this condition a primary diagnosis.
Guidelines Used To Develop The Primary Diagnosis
The guideline used in developing this primary diagnosis is the American Academy of Pediatrics. According to this guideline, healthcare professionals should diagnose children with the condition of the have moderate to severe bulging of the tympanic membrane (Lieberthal et al.,2018). The children should also have symptoms such as the onset of ear pain shown by rubbing, tugging, and holding of the ear among nonverbal children
Differential Diagnoses With Rationale And Resources
- Pertussis (ICD 10 Code: A37.0): This is a condition also commonly known as whooping cough. It is a respiratory tract infection that is highly contagious, and patients usually have a severe hacking cough, which is usually followed by a high-pitched breath intake. The symptoms include cough, fever, red, watery eyes, nasal congestion, and runny nose (Jenkins et al.,2020). The patients showed some of these symptoms. Hence, it is a possibility.
- Croup (ICD 10 Code: J 05.0): This condition is also known as acute obstructive laryngitis. It is usually caused by a viral infection and causes the swelling of the trachea and larynx, which then makes the airway narrower hence causing complications with breathing. The symptoms include cough, runny nose, fever, hoarse voice, breathing with squeaky high-pitched noise, and the skin between the child’s ribs sucking in during breathing (Smith et al.,2018). This condition is less likely since the patient lacked most of these symptoms
- Influenza (ICD 10 code: J10.1): This is also among the differential diagnoses. Some of the symptoms include fever, aching muscles, chills, sweats, headache, persistent and dry cough, breath shortness, weakness and tiredness, runny nose, sore throat, and eye pain (Uehara et al.,2020). The patient also lacked several of these symptoms hence making it less likely.
- Pharyngitis Streptococcal group A (ICD 10 Code: J02.0): This is a condition that can be caused by viral or bacterial infection. The symptoms include anterior cervical lymphadenopathy, palatal petachiae, pharyngeal and tonsillar erythema, fever, pain with swallowing, and sudden onset of sore throat (Oliver et al.,2018). The patient also did not display a majority of these symptoms, making this condition less likely.
- Viral Upper Respiratory Infection (ICD 10 Code: J 06.9): This condition is caused when the virus gets into the respiratory system. The symptoms include swollen nodes, sore throat, runny nose, red eyes, fatigue, hoarse voice, fever, and cough (Thomas & Bomar, 2018). The patient did not also display most of the symptoms making it less likely.
Medication, Education, Referrals and Follow-Up
These conditions can be managed using various medications. For otitis media, the child should be given amoxicillin (80 mg/kg/day divided BID) (Lieberthal et al.,2018). For Pertussis, the patient can be given azithromycin (10 mg/kg in a single dose on day 1 (maximum: 500 mg); then 5 mg/kg per day (maximum: 250 mg) on days 2 through 5). For Croup, the child should be given dexamethasone (Oral, IM, IV: 0.6 mg/kg once). For influenza, the child should be given peramivir (Oral, IM, IV: 0.6 mg/kg once). Pharyngitis Streptococcal group A can be treated using penicillin (250 mg twice daily or three times daily). Finally, the viral upper respiratory infection can be managed using azithromycin (10 mg/kg in a single dose on day 1 (maximum: 500 mg). As part of education, the patient’s mother should be directed to ensure that they adhere to the prescribed medication. In case of any adverse effects, then the patient must be brought to the facility immediately (Lieberthal et al.,2018). The patient does not need a referral at this moment but should use the medication and come for a follow-up after two weeks. A review will be done to see if any referrals are needed.
Problem Statement
It is evident that the patient has symptoms making him comfortable. Being that the patient is only two years old and, therefore, cannot fully express what he is feeling, a comprehensive diagnosis is important. Therefore, the treatment and management should majorly focus on the primary diagnosis.
Social Determinants of Health to Consider
The social determinants of health to consider include social support. The patient is a minor and fully depends on the mother for survival; hence the mother should fully support him in recovery (Donkin et al.,2018). The other factor is economic background. It is important to determine if the mother has money to buy the prescribed medication.
Health Promotion and Risk Factors.
Health promotion would help the patient. Therefore, the mother should be informed to help the patient position the child well, ensuring that the head is raised on pillows, applying a warm hot water bottle or heating pad, and breastfeeding the baby to improve natural immunity. The family should also be taught that it is appropriate to cover noses and mouths when coughing or sneezing and wash hands as frequently as possible (Venekamp et al.,2020). Some of the risk factors include family history, young age, low or premature birth weight, altered immunity, neuromuscular diseases, and craniofacial abnormalities.
Conclusion
This management plan has focused on a two-year-old child who was brought to the facility by the mother. He complained of a dry cough and runny nose. The primary diagnosis addressed is otitis media, and a plan for medication, patient education, follow-up, health promotion, and risks have all been explored.
References
Donkin, A., Goldblatt, P., Allen, J., Nathanson, V., & Marmot, M. (2018). Global action on the social determinants of health. BMJ global health, 3(Suppl 1), e000603. http://dx.doi.org/10.1136/bmjgh-2017-000603
Jenkins, V. A., Savic, M., & Kandeil, W. (2020). Pertussis in high-risk groups: An overview of the past quarter century. Human Vaccines & Immunotherapeutics, 16(11), 2609–2617. https://doi.org/10.1080/21645515.2020.1738168
Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., … & Tunkel, D. E. (2018). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. https://doi.org/10.1542/peds.2012-3488
Oliver, J., Malliya Wadu, E., Pierse, N., Moreland, N. J., Williamson, D. A., & Baker, M. G. (2018). Group A Streptococcus pharyngitis and pharyngeal carriage: a meta-analysis. PLoS Neglected Tropical Diseases, 12(3), e0006335. https://doi.org/10.1371/journal.pntd.0006335
Smith, D. K., McDermott, A. J., & Sullivan, J. F. (2018). Croup: diagnosis and management. American Family Physician, 97(9), 575–580. https://www.aafp.org/pubs/afp/issues/2018/0501/p575.html
Thomas, M., & Bomar, P. A. (2018). Upper respiratory tract infection. https://europepmc.org/article/nbk/nbk532961
Uehara, T., Hayden, F. G., Kawaguchi, K., Omoto, S., Hurt, A. C., De Jong, M. D., … & Kida, H. (2020). Treatment-emergent influenza variant viruses with reduced baloxavir susceptibility: impact on clinical and virologic outcomes in uncomplicated influenza. The Journal of Infectious Diseases, 221(3), 346–355. https://doi.org/10.1093/infdis/jiz244
Venekamp, R. P., Schilder, A. G., van den Heuvel, M., & Hay, A. D. (2020). Acute middle ear infection (acute otitis media) in children. Bmj, 371. https://doi.org/10.1136/bmj.m4238
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Management Plan Template– must include these headings
Primary Diagnosis with ICD-10 code, rationale and resources. Include CPT codes, and any procedural codes, including nurse lab draws, vaccinations given, biopsies, etc…10 pts.
Guidelines used to develop this primary diagnosis. 5 pts
Differential diagnoses with rationale and resources. 3-5 Ddx required, unless well visit. 5 pts
Medications including OTC, dosage and education, additional ancillary tests needed, referrals and follow up – 10 pts
Problem Statement – 5 pts
Social Determinants of Health to consider, Health Promotion and Pt risk factors – 5 pts
Must use 3 scholarly references the course text may NOT be used as a reference. The references must be professional and not general patient education websites.
Worth 40 points
Case Study:
2-year-old male presents to office with his mother for a dry cough and runny nose, started 2 days ago. Mother reports pt has a fever that started yesterday, the highest temperature reported by patient’s mother is 101.0 F. He is currently taking Tylenol for fever. Mother states it gives pt relief and returns in 4 hours. Pt immunizations are up to date, but he has not received the flu shot this year due to getting sick from last year flu shot. Pt mother states his appetite has decreased since being sick. Pt attends daycare with several children who are sick. Mother denies any rash, nausea, vomiting, discharge from ear, or pulling ears.
Primary Diagnosis: Otitis Media
Differential Diagnosis:
Pertussis, Croup, Influenza, Pharyngitis streptococcal group A, Viral upper respiratory infection
