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Practicum Journal Entry
Children are brought by their parents to the clinic with complaints that seems to be straightforward, with most being treated appropriately. However, as advanced nurse practitioner, I am faced by the responsibility to ensure that the patient is diagnosed correctly and the disease is managed effectively. However, making of correct diagnosis can be elusive and in most cases, it will require the APN to carefully consider the possible differentials as well as identifying the most appropriate strategy to manage the problem (Burn et al., 2013).
During the practicum, a 9 year old boy of Hispanic origin reported to the clinic with sore throat and higher fever (1030F), malaise headache and general body weakness. The patient Lymph nodes were swollen. The patient had attended a local clinic where she was diagnosed with streptococcal pharyngitis and was administered with Omnicef 14 mg/kg/day. However the patient condition worsened after 3 days, and the mother was concerned that the child could be suffering from something else (Murray & Chennupati, 2012).
Practicum Journal Entry
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To identify the core area of the child current situation, I employed helpful tool of the pneumonic NEEDS. NEEDS is an acronym that stands for Nutrition, Elimination, Environment/Education, Daycare/ Development and Sleep/ Sexuality (Murray & Chennupati, 2012). In this context, nutritionally, the patient reported difficulty in swallowing but was able to drink cool liquids. The patient elimination was normal as she voided normal stool at least four times a day.
The assessment of the patient education and environment indicated that the patient was doing fine, and that she had not been exposed to sick friends or family friends. The patient general care was good and was involved in Drama club, although the patient missed practice this week. Patient rest is adequate as the she sleeps approximately for 9 hours a night, but have been sleeping for more than 12 hours since the onset of the disease. The patient reported that she had ensured medication adherence, and denied presence of persistent illness in the past (Murray & Chennupati, 2012).
In some cases, when making differential diagnoses, there could be loop holes that can make diagnoses be missed. In this case, specific and sensitive diagnostic tests should be done to facilitate accuracy, cost and precision. In this case, the poor response to antibiotics and patient clinical manifestation of persistent fever, fatigue, tonsillitis and lymphadenopathy made me consider presence of other infections such as infectious mononucleosis (IM). Other differential diagnoses that were considered included acute leukaemia, tumours of the neck, Hodgkin’s disease. Allergies are also associated with throat pain and pharyngeal tickling (Thompson, 2015).
Practicum Journal Entry
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I conducted patient physical examination, where the patient weight, Bp, BMI and height were on the 50th percentile for the patient. The remarkable physical observations were +3 erythematous tonsils that had no exudate. Tonsillar nodes were swollen. The nodes were tender and soft. Patient chest was clear and the heart sounds were normal. All other systems were reviewed and were intact. The laboratory findings were positive for IM (Burn et al., 2013).
However, the diagnosis process posed some challenges. This is because I relied in the initial impression of the clinical diagnostic, and had failed to reconsider the new data obtained during the revaluation. This is because my confidence was low, and was not keen to work with the results that I had gathered from patient assessment. It took the intervention of my preceptor, who helped me reconsider the new data gathered to frame the diagnostic options. My preceptor cautioned against this behaviour. I was also warned about premature closure, where the APN may prematurely close other potential diagnostic possibilities (Thorburn, 2010).
The final diagnosis was IM; however, there is no direct treatment for this disease. The treatment plan was to control patient clinical manifestation. This includes controlling patient fever; maintain patient body hydrated, adequate rest, and the treatment of secondary infections. Treatment is symptom based. The patient was given antipyretics to manage the patient fever. The patient was advised to be in light clothes to facilitate the dissipation of heat.
Practicum Journal Entry
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Appropriate foods as well as liquids were suggested to the mother so as to avoid irritation of the throat. This was done putting consideration of cultural sensitivity to ensure that the food selected would be tolerated by the family. I did not see the need for the patient to continue with Omnicef, but my preceptor advised that group A streptococcus is a secondary infection for patients diagnosed with IM, so the patient should continue with the mediation (Murray & Chennupati, 2012).
As an APN, it was my responsibility to educate the family about the disease, causes, symptomatic and treatment. I educated the patient on importance of finishing the dosage for fever and to avoid use of multiple blankets. The patient is taught the benefits of completing medication to manage the secondary bacterial infections even if it fails to make other clinical manifestation such as sore throat, fatigue and fever to disappear. The benefits of hydration were also monitored (Burn et al., 2013).
References
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care(5th ed.). Philadelphia, PA: Elsevier.
Murray, R., & Chennupati, S. (2012). Chronic Streptococcal and Non-Streptococcal Pharyngitis. IDDT, 12(4), 281-285. http://dx.doi.org/10.2174/187152612801319311
Thompson, A. (2015). Infectious Mononucleosis. JAMA, 313(11), 1180. http://dx.doi.org/10.1001/jama.2015.159
Thorburn, K. (2010). Case Studies in Pediatric Critical Care. Critical Care, 14(1), 301. http://dx.doi.org/10.1186/cc8836
Practicum Journal Entry
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