The Comprehensive Case Write- Up Assignment

The Comprehensive Case Write- Up Assignment

Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc. This write up should be 5-8 pages single spaced. The Comprehensive Case Write- Up Assignment

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Patient particular’s

Initials: J.H

Age: 8 years old

Gender: male

Subjective Data

Chief compliant: coughing and difficulties in breathing for three days

History of presenting illness: J.H is an 8years old male accompanied by his mother at the emergency department complaining of a cough and difficulties in breathing for three days. The cough was of acute onset triggered by exposure to a cold environment, worse during the morning and evening. The cough is productive with thick whitish sputum. There are no relieving factors to the cough. The patient also presents with difficulties in breathing on exertion and when talking. He cannot complete a sentence without posing. Other symptoms are chest pain, chest tightness, shortness of breath, fatigue, difficulties in eating, and wheezing. The mother states that he experiences such symptoms weekly when exposed to cold, exertion, dust, and smoke.

Past medical history: the patient has a history of recurrent allergic rhinitis. During his infancy, he was hospitalized severally due to recurrent acute bronchitis, chronic tonsillitis, and once due to severe pneumonia. The mother denies diagnosis of chronic diseases like cancer, diabetes, and mood disorders.

Past surgical history: the patient has undergone a tonsillectomy at the age of 6 years. He denies major surgical procedures. The Comprehensive Case Write- Up Assignment

Current medication: cetirizine 5mg PO once daily or PRN for allergic rhinitis

Immunization: his immunization schedule is up to date. He had his hepatitis B vaccine within 12 hours after birth, the second dose after two months, and the third dose at the age of one year. He was vaccinated against rotavirus at the age of 6 weeks and 10 weeks. He was vaccinated against Diptheria, tetanus, and pertussis at the age of six weeks, ten weeks, six months, eighteen months, four years, and six years. He has received four doses of Haemophilus influenza at the age of six weeks, ten weeks, six months, and eighteen months. He has had five doses of pneumococcal vaccine at the age of six weeks, ten weeks, sim months, eighteen months, and at the age of four years.  He has had four doses of inactivated polio vaccine at six weeks, four months, eighteen months, and six years. He has had three doses of measles, mumps, and rubella at the age of 9 months, eighteen months, and fours old. He has had two doses of varicella vaccine to protect against chicken pox at the age of one year and four years. He got his meningococcal vaccine at the age of three years. His last tetanus vaccine was six months ago.

Allergies: the child is allergic to amoxicillin because he develops a rash and hives when he takes the drug. He is allergic to cold air, dust, smoke, and fur because he develops nasal congestion, skin rash, running nose, and sneezing when exposed. He takes cetirizine to relieve the allergic events. He denies food allergies.

Family history: the patient is the thirdborn in a family of four. His siblings and parents are alive. His father is 40years and has recurrent allergic rhinitis and gastritis. His mother 36years old has hypertension and chronic sinusitis. His elder brother 16years old has asthma. His sister 12 years old has recurrent allergic rhinitis and bronchitis. His younger brother has seasonal allergic rhinitis. His paternal grandfather has asthma, hypertension, and heart failure. His paternal grandmother has chronic obstructive pulmonary disease due to tobacco smoking. His maternal grandmother has a history of recurrent rhinitis and chronic sinusitis. His maternal grandfather passed on at the age of 70years due to a heart attack. The mother denies a family history of cancer, mental health diseases, diabetes mellitus, and endocrine diseases.

Social history: the child lives with his parents and other siblings. They live in a low social economic status because their parents are struggling with unemployment. They live in a single room the six of them and it is poorly ventilated. They have no access to quality healthcare because of insufficient family funds. He is currently and grades two and his performance is above average. He enjoys playing football and reading storybooks. He is an obedient child at home and in school. His parents are smokes tobacco and marijuana in the house. They do not have smoke detectors at home.

Developmental milestones: at the age of two months, the child had a social smile, made other sounds, and acquired head support. At four months, he could hold a toy, sit with support, and make sounds. At the age of six months, the child could sit without support, know familiar people, and reaches to grab toys. At the age of 9 months, he could make facial expressions, look for objects, get to a sitting position by herself, and crawl. At the age of one year, the child could wave goodbye, put things in a container, pull up to stand, walks holding furniture, and picks things between the thumb and the pointer finger. At the age of eighteen months, he could walk without support, feed himself from his fingers, climb on and off the couch, point at something, and utter at least three words. At two years he could point and mention at least two body parts, hold something using one hand, kick a ball, run, and eat with a spoon. At the age of three years, he could respond to a conversation using a few words, he could put on clothes by himself, mention his name, and draw a circle. At the age of four years, he could mimic, avoid dangers, and say a sentence of more than four words. At the age of 5 years, the child could follow rules and take a turn in a game, can tell a story, can keep a conversation with more than three exchanges, and can hop on one foot. At the age of 8 years, the child can read sentences, enjoy being around friends, rapidly changing emotions, and has a well-developed speech.

Review of systems

General: the patient denies malaise. Headache, weight loss, night sweats, chills, rigors, and fever.

HEENT: the patient denies headache, dizziness, eye ache, blurring of vision, tearing of the eyes, ear fullness, facial fullness, nasal congestion, stuffy nose, epistaxis, running nose, change of vocals, throat pain, and loss of hearing.

Cardiovascular system: the child has chest pain, cough, wheezing, breathlessness, and dyspnea. However, the mother denies dizziness, palpitations, ankle swelling, paroxysmal nocturnal dyspnea, and orthopnea The Comprehensive Case Write- Up Assignment.

Gastrointestinal system: the patient denies dysphagia, reflux, indigestion, flatulence, vomiting, anorexia, constipation, diarrhea, abdominal pain, abdominal distension, alteration of bowel patterns, weight loss, hematemesis, rectal bleeding, jaundice, and itching.

Genital urinary system: the patient denies dysuria, hematuria, oliguria, nocturia, polyuria, frequency of micturition, and urethral discharge.

Neurological system: the patient has no history of seizures, collapses, dizziness, numbness, transient paresthesia, facial droop, muscle weakness, and paralysis.

Endocrine system: the patient has no body weakness, unintended weight fluctuations, mood swings, changes in blood glucose, high blood pressure, changes in cholesterol levels, excessive hunger and thirst, sleep apnea, constant urination, food cravings, loss of hair, intolerance to cold or heat, difficulties in sleeping, nausea, and vomiting.

Lymphatic system: the patient denies painless swelling of the lymph, fever, itchy skin, night sweats, skin discoloration, blisters, frequent infections, fluid leaking from the skin, difficulties in swallowing, drooling, and difficulties in talking.

Hematologic system: the patient denies a history of easy bruising of the skin, muscle weakness, trouble concentrating, chronic infections, malaise, dizziness, headache,  uncontrolled bleeding, and chronic weight loss.

Psychiatric: the patient denies social withdrawal, loss of interest, impaired memory, loss of concentration, bizarre behavior, and anxiety The Comprehensive Case Write- Up Assignment.

Objective Data

General: The patient is oriented to time, place, and person. He is calm and well-dressed for the environment. He has no pallor, edema, dehydration, jaundice, cyanosis, lymphadenopathy, or finger clubbing.

Vitals: Temperature at 36.9, blood pressure at 105/84mmHg,  Heart Rate-112beats per minute, Respiratory rate is 26 breaths per cycle,  O2 sat88% room air, and BMI at 26kg/m².

Respiratory system: the child is in respiratory distress and uses accessory muscles for breathing. He has rapid and shallow breaths, lower chest wall indrawing, flaring of nasal alae, and intercoastal resection. The chest walk expansion is symmetrical during respiration. There are no scars, bruises, or masses. There is a hyper-resonant percussion note all over the lung fields. There is no tenderness and organ enlargement on palpation. Upon auscultation, the lung fields there are bronchiole breath sounds, rhonchi, wheezing, and basal crackles.

Integumentary/Skin: the patient’s skin color is uniform and consistent with his ethnicity. It is warm with good skin turgor and capillary refill. There are no open wounds and soreness, skin dryness, flaking, and bruising. The hair distribution is moderate. The nails are soft and smooth with no evidence of finger clubbing The Comprehensive Case Write- Up Assignment.

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HEENT: the head is a-traumatic, normal-cephalic without masses, bruises, or lesions. The hair is clean with no scalp scales. The head is non-tender with no palpable mass. The eyes are in the right position with no discharge, tearing, crusting, peri-orbital edema, or redness. The retina is intact with no signs of bleeding and cataracts. The hearing function is intact for both high medium and low medium pitches. There is no accumulation of wax, redness, swelling, or discharge at the inner ear. The nose is round. The mucus membrane is pink and moist. There is no nose bleeding or nasal discharge. The mouth has no visible ulcers, oral candidiasis, and inflammation of the tongue. The gum is clean with a pink color, holding natural teeth. The neck is round with normal skin color. There is no visible mass. On palpation, the neck is soft and non-tender. There is no venous enlargement.

Cardiovascular system: the peripheral pulse is present at a normal volume, regular rate, and rhythm. The neck veins are not distended. The heart sounds S1 and S2 are present at the 5th intercostal space mid-clavicle line. There are no parasternal heaves, rubs, gallops, and murmurs heard o palpation. There is no bilateral lower limb edema.

Gastrointestinal system: the abdomen is round with a normal contour. The bowel sounds are present at a normal rate and rhythm. There is a tympanic percussion note. There is no shifting dullness or fluid thrills. There are no areas of tenderness an organ enlargement upon palpation. The liver span is 1cm.

Genital and Rectal:   The external genitalia is of normal size and shapes for his age. The penis has a normal skin color and shape, without scars. The foreskin is present without discharge and bruises. The scrotum is dark and cool, with normal size and shape. The testes are present and non-tender.

The rectum: the anal opening is pink and moist. The anal sphincter has a good tone. There are no fissures, ulcerations, mass, anal piles, discharge, or hemorrhoids The Comprehensive Case Write- Up Assignment.

Musculoskeletal/Peripheral Vascular: the patient assumes an upright posture and gait. The muscle tone, bulk, and power are normal. The patient perceives dull, sharp, and light touch. The joints easily flex and extend with no stiffness. There is no crepitus perceived upon joint movement. There is no swelling around the joints and at the extremities. There is no kyphosis, scoliosis, or kyphoscoliosis noted. There are no sensory deficits.

Neurologic: the patient is oriented to time, place, and person. He responds well during the interview, soft-spoken with a low volume, and soft tone. The patient is actively listening and maintaining eye contact. The thought process is future-oriented and positive. He has no hallucinations or suicidal ideation. He obeys commands both simple and complex. The cranial nerves and the tendon reflexes are intact.

Psychiatric assessment: the child is oriented to time, place, and person. He maintains eye contact during the interview. He responds to the conversation promptly though he seems to be struggling. He is in a low mood and blunted affect. His insight and judgment are intact. He denies suicidal ideation, hallucinations, and delirium.

Assessment

Differential diagnoses

1. Acute asthma
2. Seasonal allergic rhinitis
3. Pediatric bronchitis
4. Pneumonia
5. Acute pharyngitis

Primary diagnosis: asthma is a reversible inflammation of the airway that causes airflow obstruction and bronchial hyperresponsiveness. It is a non-communicable disease that affects both children and adults, and it is the most common chronic disease in childhood. According to the data collected in 2019, more than a 262million people have asthma and more than 500,000 have died out of it (Dharmage, et al, 2019). Asthma is common in low-income families or communities and is usually underdiagnosed and undertreated due to a lack of access to quality healthcare services. Asthma negatively affects their daily life because it causes sleep disturbances, tiredness, and poor concentration. The risk factors for asthma are the presence of allergic diseases like eczema and rhinitis, family history of asthma, and exposure to a range of outdoor irritants like air pollution, house dust, mites, mold, dust, smoke, and chemicals. In asthma, there is an acute or chronic inflammation of the airway after exposure to an allergen or trigger causing edema and mucus hypersecretion, smooth muscle hyperplasia, and bronchospasms which causes wheezing, difficulties in breathing, shortness of breath, coughing, and chest tightness.

The physical signs are intercoastal muscle resection, nasal flaring, lower chest wall indrawing, tachycardia, wheezing, and breathlessness when talking. Airflow obstruction is a result of bronchospasms and chronic mucus plug formation. Bronchial hyperresponsiveness helps in compensating for uneven airway circulation or distribution due to airflow obstruction. Causes of asthma in children are exposed to environmental allergens like animal fur, pollen, dust, and smoke. Viral respiratory infections like rhinoviruses may induce asthma. Physical exercise causes hyperventilation, hence causing asthma. Environmental pollutants like tobacco smoking. This is the child’s actual diagnosis because he presents with wheezing, difficulties in breathing, coughing, and chest pain. the child is known to have asthma since the age of two years and has recurrent seasonal allergic rhinitis. The onset of these symptoms was after engaging in physical exercise in cold weather. Additionally, he has a positive family history of asthma from his paternal grandmother and mother. His parents smoke tobacco in the house regularly, thus increasing the risk for asthma. According to Dharmage, et al, (2019), blood eosinophils, serum immunoglobulins, arterial blood gas, periostin, pulse oximeter assessment, and bronchoprovocation are the diagnostic tests specific for confirmation of asthma.

Differential diagnoses

Seasonal allergic rhinitis is an atopic upper respiratory tract disease presenting inflammation of the nasal membranes. It has a prevalence rate of 8% affecting over 20 million adults and children. Over 80% of these cases occur in children less than 20 years. The highest prevalence rate of allergic rhinitis is highest in Africa and Latin America. The clinical signs and symptoms are sneezing, itchiness of the nose, ears, and eyes, rhinorrhea, post nasal drip, congestion, anosmia, headache, ear ache, tearing, fatigue, malaise, drowsiness, and cough. The physical examination findings are watery mucus secretions, the presence of a nasal crease, ear fullness, allergic conjunctivitis, and cobblestoning at the posterior pharynx (Malizia, et al, 2021)The Comprehensive Case Write- Up Assignment.  Allergic rhinitis involves the inflammation of the mucous membranes of the nose, eye, middle ear, eustachian tubes, middle ear, sinuses, and pharynx. This causes the production of inflammatory mediators triggered by immunoglobulin IgE response to an extrinsic protein such as pollen and other allergens. These mediators coat the mucosa membranes leading to the production of mast cells and histamine that causes symptoms like rhinorrhea, nasal congestion, itchiness, redness, swelling, ear pressure, post nasal drip, and sneezing.

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The inflammatory mediator triggers the release of neutrophils, eosinophils, lymphocytes, and macrophages that causes systemic symptoms like sleepiness, fatigue, and malaise. However, for appropriate diagnosis and early treatment, patients with a stuffy nose, nasal passage discoloration, and red watery eyes should do a sinus imaging process of specific immunoglobulin E screening. Other specific tests are skin allergy testing for hypersensitivity and fluorescence enzyme immunoassay to measure the quantity of IgE. Complications for allergic rhinitis are chronic sinusitis, otitis media, sleep apnea, dental problems, palatal abnormalities, and eustachian tube dysfunction. The patient has a history of recurrent allergic rhinitis during the cold weather and presents with similar symptoms like coughing, mucus secretion, and fatigue. However, it is not the actual diagnosis because he does not present with post nasal drip, itchiness, and sneezing The Comprehensive Case Write- Up Assignment.

Acute bronchitis is the inflammation of the airway (trachea, bronchi, and bronchioles). It is a common respiratory tract infection whose etiology is a viral or bacterial infection. It is more common in children younger than 15 years old. More than 10 million patients worldwide visit the hospital due to acute bronchitis (Gallucci, et al, 2020). The prevalence rate is equal in both males and females across all regions of the world. Common pathogens are rhinovirus, adenovirus, and influenza virus. Bacterial pathogens are streptococcus pneumonia, H. influenza, and chlamydia. Triggers of bronchitis are air pollutants like smoking and other environmental allergies. Bronchitis is a result of recurrent lower respiratory tract infections that causes degeneration of mucosal membranes in the trachea and bronchus.

The clinical symptoms are coughing, retrosternal chest pain, malaise, chills, low-grade fever, sore throat, nasal discharge that is initially watery and later becomes thick and colored, hemoptysis, dyspnea, wheezing, and breathlessness. The physical examination findings are crackles, rhonchi, and wheezing. Infestation of viral or bacterial pathogens at the lungs, trachea, or bronchi causes inflammation of the airway and hypersecretion of mucus, hence the formation of phlegm. This causes airway obstruction and irritation of the lungs, hence coughing, sputum production, and wheezing (Gallucci, et al, 2020). The patient presents with similar symptoms; coughing, difficulties in breathing, chest pain, and wheezing. The confirmatory diagnostic tests for bronchitis are throat swabs for culture, chest radiography, bronchoscopy, and prolactin levels.

Pneumonia is a bacteria infection of the lungs caused by bacteria, fungi, and viruses. It is the leading cause of death among children under the age of five years. The world health organization WHO is minimizing the prevalence of pneumonia in children and the very elderly by encouraging immunization and adequate nutrition by addressing the environmental factors. The infectious agents causing pneumonia are streptococcus pneumonia, Haemophilus influenza, and HIV pneumocystis jiroveci (Fritz, et al, 2019). Pneumonia causes infection of the lung parenchyma causing fibrosis and consolidation at the alveoli. Pneumonia infection is classified according to the anatomical distribution, mechanism of acquisition, and the pathogen causing infection. Anatomical types of pneumonia are lobar, multifocal, and interstitial. The setting of acquisition can be community-acquired, nosocomial, or hospital-acquired pneumonia.

The pathogen causing pneumonia gets into the lungs through exposure to pulmonary irritants. Inhaled infectious organisms pass by the host defense mechanism to cause pneumonia. The respiratory tract host defense mechanism causes airway secretions that provide a physical barrier minimizing the epithelia adhesions. In children with low immunity, there is increased physical disruption of these epithelial barriers, interfering with ciliary function and ciliary integrity. The presenting symptoms are coughing, headache, chest pain, congestion, fever, decreased feeding, and congestion. The signs are respiratory distress,  flaring of nasal alae, intercoastal muscle resection, tachypnea, grunting, cyanosis, purulent mucus, stridor, crackles, and diminished air entry. The patient presents with similar symptoms as pneumonia. The diagnostic tests that would help make the diagnosis of pneumonia are high white blood cell count, high erythrocytic sedimentation rate, and blood culture and sensitivity showing the presence of streptococcus or Haemophilus influenza. This is not the actual diagnosis because the patient dies not to meet the CURB-65 criteria for pneumonia The Comprehensive Case Write- Up Assignment.

Acute pharyngitis is the inflammation of the throat whose etiology can be fungal, bacterial, or viral pathogens. Group A streptococcus is the most common cause of acute pharyngitis. Other causes are trauma, toxins, and neoplasia. Pharyngitis is the most common upper respiratory tract infection among children with a prevalence rate of 30%. The viral infections in pharyngitis are self-limiting. Bacterial pathogen invades the mucosa causing inflammation and release of toxins and proteases. The presenting symptoms are headache, throat pain, hoarse voice, fever, running nose, white-grey patches on the back, swollen or sore glands of the neck, anterior cervical lymphadenopathy, tonsillar exudate, conjunctivitis, sclera icterus, palatal petechiae, non-productive cough, murmurs, sandpapery rash, and dehydration. The risk factors for acute pharyngitis are overcrowding, history of contact with a sick patient, allergic rhinitis, cold season, smoking or exposure to smoke, and frequent sinus infections. The accurate diagnostic tests are a culture for throat swab group A streptococcus, rapid antigen test for group A streptococcus, mono spot for Epstein-Barr virus infection, complete blood count with white blood cells differentials, inflammatory markers, and peripheral smear to show typical lymphocyte infection. This is not the patient’s diagnosis because has no skin changes The Comprehensive Case Write- Up Assignment

Plan

The patient has persistent asthma because he has had similar symptoms weekly without improvement. Moreover, his symptoms are moderate to severe caused by exposure to the allergen and genetic predisposition.

Diagnostic investigations

Laboratory investigations and imaging helps in making an accurate diagnosis, monitoring treatment,  and ruling out other differential diagnoses. The laboratory investigations include blood eosinophils, serum immunoglobulins, arterial blood ga, periostin, pulse oximeter assessment, chest radiograph, chest CT scanning, skin allergy testing, pulmonary function testing, bronchoprovocation, exercise testing, escaping hyperventilation, allergen-inhalation challenge, complete blood count, throat swab for culture and sensitivity, and blood culture. Blood eosinophilia more than 4% supports the diagnosis of asthma and helps rule out pneumonia and bronchopulmonary aspergillosis. Serum immunoglobulin E is not a specific test for asthma but helps in identifying the trigger factors such as allergic rhinitis. Arterial blood gas analysis measures oxygen circulation in the body organ, hence revealing hypercarbia and hypoxemia due to hypoventilation. Periostin is a biomarker for asthma because it suggests eosinophilic inflammation of the airway that occurs during asthma. It helps in determining well-controlled asthma on inhaled corticosteroids. Pulse oximeter assessment measures the blood circulation in the body to grade the severity of asthma The Comprehensive Case Write- Up Assignment.

A chest radiograph helps to determine complications and other alternative causes of wheezing. It helps rule out conditions like bronchitis and pneumonia. A high-resolution chest CT scan is useful in this patient because it shows bronchiole wall thickening, bronchiole dilation, reduced airway lamina, mosaic lung attenuation, mucus impaction of the bronchi, and linear trapping. HRCT helps in making the appropriate diagnosis for bronchiole asthma and ruling out other diseases affecting the lung parenchyma like pneumonia. Allergy skin testing is not specific for asthma but helps diagnose allergic rhinitis. The pulmonary testing function involves spirometry assessment that is specific for asthma diagnosis. Forces vital capacity demonstrates the presence of airway obstruction and the reversibility after administration of a bronchodilator. Complete blood count with white blood cell differentials helps determine the presence of an infection and allergic reaction to rule out pneumonia, chronic bronchitis, and allergic rhinitis. A throat swab for culture and sensitivity helps to determine the pathogen causing the diseases. It rules out pathogens causing bronchitis, pharyngitis, and pneumonia. Exercise testing helps in assessing for exercise-induced bronchoconstriction by exposing the patient to 6 minutes of extraneous exercise. Sinus CT scanning is helpful to exclude chronic sinusitis which is a contributing factor to asthma. Bronchoprovocation tests help in determining if airway hyperactivity is present. A negative result excludes the diagnosis of asthma. The Comprehensive Case Write- Up Assignment

Pharmacologic treatment

1. Assess the air for patency and assess breathing. Give oxygen supplementation at 5liters per minute to maintain saturation above 98%.
2. Nebulize the child with salbutamol in a ratio of 0.5mls:1mls of saline three times each 30minutes interval, monitoring for changes.
3. Intravenous methylprednisone 40mg. It is a bronchodilator that helps in reversing acute exacerbations.
4. Antibiotics for example ceftriaxone 500mg intravenous twice daily for five days. Penicillin is the first-line treatment therapy is patients with respiratory tract infections but is contraindicated in this patient due to allergic reactions.
5. Admit the patient if he fails to improve if the symptoms of fatigue worsen and if there is a significant decrease in oxygen circulation.
6. Discharge the patient on long-acting and short-acting corticosteroids such as a budecort inhaler two pulls twice daily and a Ventolin inhaler. Ventolin inhaler or albuterol is a bronchodilator that relaxes the muscles of the airway in the event of an asthmatic attack. It is a quick-relief inhaler for sudden asthmatic attacks. Budecort inhaler is a corticosteroid used for the maintenance treatment of asthma. It prevents the recurrence of asthmatic symptoms like wheezing and chest tightness.
7. Oral corticosteroids like prednisone tablets 1omg once daily to prevent inflammation of the airway.
8. Allergen immunotherapy to prevent recurrence of asthma
9. Omalizumab subcutaneous injection once biweekly. It is recommended for patients with a positive skin test and the symptoms are inadequately controlled by the corticosteroids The Comprehensive Case Write- Up Assignment

Non-pharmacological: Environmental exposure triggers symptoms exacerbation of asthma. Patient avoidance of environmental irritants would help reduce the frequency of asthmatic attacks. This child is allergic to cold weather, dust, fur, and pollen. Therefore, he should minimize contact with these environmental triggers to avoid exacerbation of asthma. The patient should avoid contact with smoking from his parents. The child should have adequate nutrition to boost his immunity. Moreover, the patient should avoid the use of non-steroidal anti-inflammatory drugs and food additives.

Follow-up: The patient should be under long-term monitoring for signs and symptoms of asthma. The patient is educated on the symptoms of inadequate asthma control. The patient should have frequent monitoring of pulmonary functions to prevent complications. The patient should however consult a pulmonologist and allergist to ensure proper stepwise management of asthma and evaluate other differential diagnoses.

Patient education: the child should be integrated for child care treatment of asthma. Patient education will involve the nurse, pharmacist, and respiratory therapist to train on signs of asthma, triggers of asthma, how to take medication, and how to prevent asthma symptoms at home. The pharmacist emphasizes the role of medication and inhalers in the prevention of asthma. The family members should understand the danger signs of asthma to enable prompt emergence response. The nurse writes a care plan for the patient to ensure proper treatment and achievement of treatment goals.

Health promotion: asthma is a fatal illness among children causing the majority of infant mortalities. Often, asthma diagnosis is missed out for acute bronchitis because they have similar symptoms. Therefore, the healthcare team should understand the difference between the two to prevent ensure proper diagnosis and treatment. The health care sector should create awareness of these respiratory diseases that causes fatalities. Understanding the symptoms of asthma enables the care provider to seek prompt treatment for the child. This reduces the burden of chronic asthma cases with poor prognosis among children.

Reflection

Assessing a child with respiratory tract disease was a good learning experience because I learned how to engage a child in a conversation. Initially, the child was rigid in responding but after creating rapport he was open to conversation. This assessment prompted me to learn the rile of developmental milestones when initiating a conversation and physical examination. The assessment was informative because the mother was cooperative and easy to consent to physical examination The Comprehensive Case Write- Up Assignment.

 References

Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in pediatrics, 7, 246.

https://www.frontiersin.org/articles/10.3389/fped.2019.00246/full

Fritz, C. Q., Edwards, K. M., Self, W. H., Grijalva, C. G., Zhu, Y., Arnold, S. R., … & Williams, D. J. (2019). Prevalence, risk factors, and outcomes of bacteremic pneumonia in children. Pediatrics, 144(1). https://doi.org/10.1542/peds.2018-3090

Gallucci, M., Pedretti, M., Giannetti, A., Di Palmo, E., Bertelli, L., Pession, A., & Ricci, G. (2020). When the cough does not improve: a review on protracted bacterial bronchitis in children. Frontiers in Pediatrics, 8, 433.

https://www.frontiersin.org/articles/10.3389/fped.2020.00433/full

Malizia, V., Ferrante, G., Cilluffo, G., Gagliardo, R., Landi, M., Montalbano, L., … & La Grutta, S. (2021). Endotyping Seasonal Allergic Rhinitis in Children: A Cluster Analysis. Frontiers in Medicine, 8. https://doi.org/10.3389%2Ffmed.2021.806911 The Comprehensive Case Write- Up Assignment

The purpose of the Case Write- Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.

Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.

Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.

If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write a note at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum or in parentheses in the plan The Comprehensive Case Write- Up Assignment.

You are learning to practice evidence-based practice. Support at least one item in the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your research is using a research article. Make sure that the article is current (5 years or less old). The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)

Note that you CANNOT redo write-ups. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

All case write ups are to be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will incur a penalty of 5 points per day including weekends (maximum deduction of 25 pt.)The Comprehensive Case Write- Up Assignment. Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date.

Episodic Write-up: Episodic visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally.  Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected.  Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.

This write-up should be 2-4 pages single spaced and concentrate on the most pertinent information. Not all the systems or sections from a comprehensive write up will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.

Comprehensive Write-up: Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive)The Comprehensive Case Write- Up Assignment, well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.  This write up should be 5-8 pages single spaced.

You must know how to delineate which visits are episodic versus comprehensive.  Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place!  Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!

Alternative Write-up: Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process. These write ups will follow the same guidelines as comprehensive-write ups.

Case Write-up Outline

Following the format of: https://meded.ucsd.edu/clinicalmed/write.htm.

Subjective:

CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”

HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Surgical History: Past surgeries and rough dates when possible. Should also include traumas and hospitalizations

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit the indication (reason) for a specific drug being taken. Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history.  If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing The Comprehensive Case Write- Up Assignment.

Allergies: Medications. Food allergies when applicable.

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For children, list dates for all immunizations.

Family History: It is generally appropriate to go back at least two generations.

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. In childbearing women, make sure to document date of last menstrual period (LMP) and methods of contraceptive use on every visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy). Every visit – If you order such a medication without documenting the above information, we have to assume that the patient could be pregnant (as would any lawyer in a lawsuit).  For a young teen you can put “not sexually active” (but make sure you have asked)The Comprehensive Case Write- Up Assignment.  This is sometimes tricky with teens being seen for general health problems but so very important.  If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.

Objective

Vital signs (BMI should be included on every visit)

Physical examination

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.

TIP:

Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section.  Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient. The Comprehensive Case Write- Up Assignment

Assessment

List both your differential diagnoses and your presumptive diagnosis. Remember that these should be supported by findings in your history and physical exam. For a comprehensive exam, you should document at least three ICD code diagnoses.

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Plan

Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed.

Coding Resource:

All write ups should include the billing codes.  We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up.  You should include both the E&M code (level of service) and the ICD-9 diagnosis codes. Your E&M code should be consistent with your patient visit. The Comprehensive Case Write- Up Assignment

MSN Case Write-Up Rubric

Criteria	Exceeds Expectations	Meets Expectations	Below Expectations	No Effort
Chief Complaint (CC)	3 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up AND is in the patient/ family’s own words.	2 Points Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words	1 Point CC is not appropriate for the type of write-up AND is not in the patient/family’s own words	0 Points  Not included
History of Present Illness (HPI)	10 points Provides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information. HPI is focused and detailed. Does not include any objective data	7 points Provides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit. HPI is somewhat focused. Does not include objective data.	4 points Provides a superficial HPI that misses 3 or more key components and/or does not include all pertinent information, includes irrelevant information OR includes objective data	0 Points Not included
Medications	3 Points Documents a comprehensive Medication list that includes drug name (brand and generic), dosage, route, frequency and indication. Allergies are documented and includes reaction. Includes NDKA, if applicable.	2 Points Documentation includes medication list but omits 1-2 details. Allergies are documented but does not include reaction.	1 Point Documentation includes medications but omits 3 or more details. Allergies are not documented	0 Points Not included
Pertinent History	10 Points Provides comprehensive past medical history, surgical, family, social, and obstetrical history (when applicable). History is consistent with other documentation. Includes immunization information	7 Points Provides a history but history is superficial AND/OR omits 1 -2 necessary details	4 Points Provides a history but history of superficial and omits 3 or more details	0 Points Not included
Review of Systems	10 Points Complete ROS that addresses each physical system for a comprehensive visit and includes only necessary (but at least 4 systems) for an episodic visit. ROS is completed with a clear narrative. Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’	7 Points Incomplete ROS that misses 3 or less components for a comprehensive visit OR includes inappropriate systems for an episodic visit	4 Points Incomplete ROS that misses 4 or more components for a comprehensive visit AND/OR includes objective data	0 Points  No ROS attempted
Objective Data	20 Points Documents vital signs with documented BMI Documents physical examination: Each system addressed completely for comprehensive exam. Includes only necessary (but at least 4 systems) for an episodic visit. Include pertinent positive and pertinent negative findings. Documents labs, diagnostic tests that are available for that visit.	14 Points  Documents vital signs but is missing BMI Documents an incomplete physical examination: missing 3 or less components for a comprehensive visit and/or missing up to 3 pertinent positives/negatives OR includes unnecessary systems for an episodic visit and/or assesses less than 3 systems Documents labs, diagnostic tests that should be a part of the plan	8 Points Does not document vital signs Documents an incomplete physical examination: missing 4 or more of the components for a comprehensive visit and/ or missing 4 or more pertinent positives/negatives OR Includes unnecessary systems for an episodic visit and/or assesses less than 2 systems Fails to document labs, diagnostic tests	0 Points Not included
Assessment	14 Points Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit. Provides at least 3 diagnoses for a comprehensive visit ICD-9 codes included with each diagnosis	9 Points Provides a presumptive diagnosis but only includes 1-2 differential diagnoses   Does not include ICD-9 codes	4 Points No differential diagnoses OR no presumptive diagnosis	0 Points No differential diagnosis AND no presumptive diagnosis
Plan	20 Points Provides a plan that includes appropriate labs/tests ordered that are pending Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included. Plan includes both pharmacological and non-pharmacological interventions Plan includes referrals and follow up details Orders are appropriate for patient visit. Rationales and citations for sources of interventions Coding and Billing included	14 Points Missing 3 or more components and/or does not include dosing and instructions for medications and/or does not include Coding and Billing	8 Points Missing 4 or more of the required components OR Plan is not supported by evidence and citations for sources of intervention are missing AND Does not include Coding and Billing	0 Points Not included or inappropriate to patient visit
Formatting/APA	10 Points No errors in  grammar and spelling . No errors in APA format Write-up is in proper format and adheres to the appropriate page limits.	7 Points Up to 3 spelling or grammar errors OR 3 APA errors Write-up is in proper format and adheres to the appropriate page limits	4 Points Up to 3 errors in spelling and/ or grammar AND/OR APA errors AND Write-up is not in proper format OR does not adhere to the appropriate page limits	0 Points 4 or more errors in spelling and/or grammar AND/OR 4 or more APA errors