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Introduction
Infectious diseases are dangerous since they spread freely and affect not only adults but also children. There are special ailments that are commonly referred to as pediatric illnesses because patients suffer from them, as a rule, at an early age. Their danger is that in case of serious complications, they can be fatal. Also, several associated symptoms make the course of treatment more difficult and worsen patients’ well-being.
To describe the typical features of the examination and assessment of patients, a special pediatric case will be considered. As an assessment tool, a standard analysis scheme will be utilized. Following all examinations, including diagnostic tests, growth and development parameters, and other valuable data, it is possible to receive a comprehensive picture of the health problem. The clinical analysis of the disease, which is performed through the assessment of various indicators of the body, makes it possible to eliminate differential diagnoses and determine a specific issue as accurately as possible.
The object of Outpatient Checkup and Primary Analysis
The object of the outpatient study is a 10-year-old white boy whom his parents have brought to their family doctor. The child has had a fever for two days and feels muscular weakness. The parents confirm the symptoms and note that the son has always been an active child. However, over two days, he manifests apathy and fatigue and complains of a cough and runny nose. Also, the parents are worried about the rash that appeared on the boy’s chest and stomach. According to the results of the initial examination, it has been decided to conduct a deep examination to test all the crucial indicators of the body.
Subjective Data Analysis
As an initial examination method, subjective data will be used. Based on conversations with the parents and the boy, valuable data may be obtained regarding the key symptoms of the proposed disease and related complications. The guideline presented by Davidson et al. (2017) describes the stages of complaint assessment and other important information that medical professionals need to take into account when providing family-centered care. As the main analysis tools, such factors will be considered as chief complaints (CC) and the history of present illness (HPI), and the information will be received from both the parents and the child.
Chief Complaints
Based on CC, the 10-year-old patient has consistently high body temperature, a runny nose, cough, and muscle weakness. Also, the parents note that their son has not slept well during the last two nights. As an additional concern, the boy shows a red rash on his chest, stomach, and parts of his neck. Over the past day, new foci of redness have been found on his hands. The child denies a sore throat and argues that the bright light makes him more sensitive.
All these facts may be used to conduct further examinations. According to Griffey et al. (2015), the complexity of the assessment and interpretation of chief complaints is the lack of informational standardization, and specific data obtained directly from patients can be misunderstood. However, in this case, the boy’s symptoms are confirmed by his parents, and it is possible to exclude the wrong interpretation of sensations. Therefore, this information will become part of the further examinations and analysis of the patient’s body indicators.
History of Present Illness
The child notes that he felt the first symptoms of the disease three years ago when he returned from school. He argues that two of his classmates did not attend school at the moment, and they have the same symptoms as he did. The boy says that the rash of his friends today is more extensive than his. Also, the child’s mother and father confirm that they communicated with the parents of the sick children, and the course of their illness is identical. The patient assesses his current condition as worsening and notes that photophobia has been added to permanent headaches.
Objective Data Analysis
Based on the information obtained through the subjective analysis of data, the epidemiological nature of the child’s disease can be noted. Wendorf, Kay, Ortega-Sanchez, Munn, and Duchin (2015) remark that the “outbreaks of infectious diseases in ambulatory care” is a common phenomenon, and a tendency to increase in the number of patients may indicate a virus coverage growth. To make sure that the symptoms suggested by the child are correct, it is essential to perform the review of systems, conduct physical examinations, and identify diagnostic findings. Also, a growth chart will be compiled for height, weight, body mass index (BMI), and tanner staging.
Review of Systems
By the review of the eyes system, there are a noticeable reddening of whites and the increased susceptibility of pupils to light, which may cause headaches. The ENT system (ears, nose, and throat) corresponds to the initial description of the patient, and the signs of inflammation are observed. The cardiovascular analysis shows increased fatigue and low stamina, which is noted by the child. Based on the review of the respiratory system, cough is observed. Constitutional symptoms indicate rash, as well as the loss of sleep and appetite.
Physical Examinations
The child shows lethargy and weak activity, indicating a breakdown. Based on the survey, the boy often plays sports, but due to the illness, he does not have the desire to perform any physical activity. Muscle tone is weak, and constant joint pain is confirmed. Due to high temperature and blood pressure, it is not possible to check the parameters of endurance on special equipment.
Diagnostic Findings
To obtain the most accurate clinical picture, an appropriate diagnosis should be made. According to the study by Hübschen et al. (2017), it is necessary to take swabs from the throat and nose, as well as blood and urine tests. Based on the results of the diagnostics, a specific virus can be identified, and an appropriate treatment plan may be prescribed. However, while the results of the tests are not obtained, it is impossible to draw unambiguous conclusions.
Growth Chart Percentiles
To obtain accurate and visually convenient information regarding patient growth data, a corresponding chart with necessary parameters will be compiled. Figure 1, Figure 2, Figure 3, and Figure 4 present the key indicators that need to be taken into account – height, weight, BMI, and tanner staging. All these data can be used as the valuable aspects of the child’s physical development, which is to be considered when making a diagnosis.
Summary Reply
The evaluation of diagnostic tests may allow determining a specific disease if all the examinations are performed by the principles of the comprehensive assessment of the body’s performance. The treated patient who is a white boy of 10 has the signs of infectious disease and complains of certain symptoms, including headaches, muscle weakness, photophobia, a runny nose, and a rash in the abdomen, chest, neck, and limbs. Based on the examinations and the initial survey, it is possible to make a possible diagnosis and compile an effective treatment plan. The careful analysis of all systems provides an opportunity to avoid mistakes and identify a specific illness.
Primary Diagnosis
The results of the initial survey, examinations, and further research allow making a primary diagnosis. According to Davidson et al. (2017), the practice of interacting with family members is an effective method of assessment, in particular, determining the epidemiological nature of the disease. According to the clinical picture, measles can be defined as the primary diagnosis. As Hübschen et al. (2017) note, the typical symptoms of this ailment are rash, fever, photophobia, and muscle weakness.
Also, “measles is highly infectious,” and the identical cases of the patient’s classmates prove that the disease can be transmitted through airborne droplets (Wendorf, Kay, Ortega-Sanchez, Munn, & Duchin, 2015, p. 589). Therefore, this diagnosis is reasonable and may be considered the primary one.
Treatment Plan
Treatment is based on reducing the severity of symptoms and preventing complications. According to Hübschen et al. (2017), the observance of the drinking regime given the possible dehydration of the body due to fever is essential in treating a patient with measles. The observance of a bed sparing regimen for 7-10 days from the onset of the disease is of prime importance. Prolonged severe illness with a pronounced effect on various organs may require a long period of rehabilitation. If complications, for instance, pneumonia or bronchitis are not detected within a few days, any antibiotic therapy will not be indicated.
Secondary Diagnosis
A secondary diagnosis that can be identified based on symptoms and laboratory diagnostics is rubella. As Hübschen et al. (2017) argue, this illness “is characterized by a maculopapular rash,” and the ailment is transmitted by airborne droplets in the same way as measles (p. 519). Through clinical tests, it is possible to determine whether the boy’s symptoms match those of rubella or measles is more likely. Although the manifestations of both diseases are similar, treatment plans will differ due to the different nature of the two illnesses.
Treatment Plan
The treatment of patients with rubella and with suspicion of it is carried out at home. As Wendorf et al. (2015) note, the hospitalization of children is carried out according to clinical indications with congenital rubella and the complicated forms of the disease. Treatment includes bed rest, a balanced diet, and asymptomatic therapy. As medications, antipyretic, antihistamine, and antiviral drugs are prescribed. Griffey et al. (2015) argue that by indications, for instance, in case of complications, antibacterial medications are prescribed.
Conclusion
The comprehensive assessment of the patient’s condition by using current examination techniques allows identifying the main problems and eliminating differential diagnoses. The subjective and objective analysis of the information makes it possible to establish the true cause of the disease and identify the symptoms and complaints in detail. By utilizing the key checkup techniques, including the review of systems, physical examinations, and diagnostic findings, it is possible to determine the typical features of a particular illness.
The detailed analysis of all body systems and comprehensive clinical diagnostics suggest that a primary diagnosis is measles, and rubella is a secondary one. Treatment plans for both diseases involve bed rest, but the child’s stay at the hospital is optional. Despite the similar symptoms of both infectious ailments, treatment plans may differ, and the child’s condition is a key factor determining a therapeutic course and necessary procedures.
References
Davidson, J. E., Aslakson, R. A., Long, A. C., Puntillo, K. A., Kross, E. K., Hart, J.,… Curtis, J. R. (2017). Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Critical Care Medicine, 45(1), 103-128. Web.
Griffey, R. T., Pines, J. M., Farley, H. L., Phelan, M. P., Beach, C., Schuur, J. D., & Venkatesh, A. K. (2015). Chief complaint-based performance measures: A new focus for acute care quality measurement. Annals of Emergency Medicine, 65(4), 387-395. Web.
Hübschen, J. M., Bork, S. M., Brown, K. E., Mankertz, A., Santibanez, S., Mamou, M. B.,… Muller, C. P. (2017). Challenges of measles and rubella laboratory diagnostic in the era of elimination. Clinical Microbiology and Infection, 23(8), 511-515. Web.
Wendorf, K. A., Kay, M., Ortega-Sanchez, I. R., Munn, M., & Duchin, J. (2015). Cost of measles containment in an ambulatory pediatric clinic. The Pediatric Infectious Disease Journal, 34(6), 589-593. Web.
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