HPI: A 14-month-old Native American boy brought in by his mom due to cough, low grade fever and runny
nose for the past 2 days. This morning, the mother noted that her son was breathing quickly and “it sounds like he
has rice cereal popping in his throat.” Mom is worried because her son seems to have a lot of “bouts of colds”. Per
mom, his oral intake is decreased. He didn’t want to eat this morning.
PE: Smiling, alert Native American boy.
VS: Temp of 99.9, pulse 112, respiratory rate is 58, Pulse ox 96%
HEENT: There is moderate, thick, clear rhinorrhea and postnasal drip.
CV: His capillary refill is less than 3 seconds
PULM: lung sounds are diminished in the bases, he has pronounced intercostal and subcostal retractions, expiratory
wheezes are heard in all lung fields.


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HISTORY:
Obtaining history in relation to the illness is vital. In addition to what she has shared,
while observing this 14-month-old and completing the assessment I would ask mom:
 What has his temperature been when you checked it at home?
 What does his cough sound like?
 Is anyone else at home ill?
 Has he been exposed to anyone that has been ill?
 Does anyone in the family have any chronic illnesses or genetic disease?
 Does anyone in the family smoke? Or has he been around that has been smoking?
 Does he go to daycare or do you watch him at home?
 Have you given him anything like Tylenol or Ibuprofen for the temperature?
 You mentioned his oral intake has decreased, what has he been drinking and how
much has he drunk in the last 24 hours? How much food has he eaten?
 How has he been sleeping?
 Where does he sleep?
 Does he cough when he is sleeping?
 Yesterday and today, has he been playing like he normally does?
 Does he cough or seem like he has trouble breathing when he is playing?
 How many times has he been sick with a cold since he was born?
 What were the illnesses?
 What medications were prescribed (if they were prescribed)?
 Did he have any reactions to the medications?
 Tell me about your pregnancy, did you receive prenatal care, how was the
delivery, was it vaginal or c-section, did he go home right away,
 Do you have pets?
 Are his vaccines up to date?
Physical Exam
During the physical exam, it is important to be observant of many things at one time.
Being attentive of many physical presentations is helpful information to go along with the history
obtained from the parent or caregiver. Since this 14-month-old is here with respiratory concerns,
I would try to keep from stressing him out. I would have mom undress him and hold him while I
listened to his heart and lungs, looked in his ears, throat, and assessed his head, neck, and
abdomen. Having him undressed allows me to visualize his skin color along with his chest and
abdomen while breathing to observe for retractions. Observing his tachypnea (RR 58),
intercostal and subcostal retractions without cyanosis (O2 96%), hearing the expiratory wheezes
are heard in all lung fields, seeing the nasal drainage, and his vitals leads me to his diagnosis and
differentials.
PRIMARY DIAGNOSIS/DIFFERENTIALS
Bronchiolitis: Viral in nature, with RSV as the primary cause, followed by other viruses
such as rhinovirus, influenza, adenovirus, and parainfluenza (Maaks et al., 2020). The American
Lung Association (www.lung.org) indicate the symptoms resemble those of a the common cold
and upper respiratory infection; rhinitis, low grade temperature, loss of appetite, and cough that
progresses after a few days to have wheezing, shortness of breath, and a worse cough. This 14-
month-old’s signs and symptoms of URI with the low-grade temperature, tachypnea, cough,
coryza (nasal inflammation), and rhinorrhea that has progressed after 2 days with a decrease in
appetite, tachypnea, wheezes, diminished lung sounds, and substernal and intercostal retractions.
Bronchiolitis is diagnosed through they physicial assessment.
Differentials:
Pneumonia- A study by Yu et al. (2019). shared RSV as a leading virus causing
pneumonia in pediatric patients. RSV is also the leading virus for bronchiolitis. Pneumonia is an
infection of the lower respiratory track and caused by bacteria and viruses. Prominent symptoms
of pneumonia is fever and cough; viral pneumonia has a gradual onset with fever whereas
bacterial tends to have an abrupt onset of fever 103.3F with chills, cough, lethargy and dyspnea
(Maaks et al., 2020).
Foreign body aspiration- Frequently involves small foods such as hotdogs, candy, fruits
such as grapes, coins, or other small objects children 6 months to 3 years of age can place in their
mouths (Engorn and Flerlage, 2015). Depending on the location of the lodged object elicits the
signs and symptoms. If small enough and food related, once lodged in the lower respiratory track
can lead to wheezing, retractions, and decreased breath sounds additionally, larger objects getting
lodged in the upper track cause cough and stridor (Maaks et al., 2020). Since this 14-month-old
has all of these symptoms and a fever, it is unlikely he has a foreign body aspiration, however it
is a possibility.
Asthma- Since mom mentioned he has “had bouts of colds” there is a chance he could
have asthma. The signs and symptoms of tachypnea, wheezing, retractions are associated with
asthma, however, asthma does not present with fever. Triggers for an asthma attack include,
sinusitis, upper respiratory infections, physical activity, and seasonal or environmental allergens
(Maaks et al., 2020).
TREATMENT
Treatment includes antipyretics such as Tylenol or Ibuprofen. Supportive therapy with
hydration, nutrition, clear nasal airways, and rest.
Tylenol OTC oral suspension 160mg/5l. Sig: (based on weight) ___ml by mouth every
4-6 hours as needed for temperature greater than 100.4F
Children’s Motrin oral suspension 100mg/5ml. 5-10mg/kg/dos every 6-8 hours for
temperature greater than 100.4F. Sig: (based on weight) __ml every 4-6 hours as needed for
pain.
Bronchiolitis does not require antibiotics, albuterol, epinephrine, nebulized hypertonic
solution, corticosteroids, or physiotherapy in the outpatient setting (Ralston et al., 2014).
Additionally, is not a recommendation to conduct x-rays and laboratory testing is not needed
when bronchiolitis is diagnosed through the physical assessment (Ralston et al., 2014).
EDUCATION
It is vital to explain to mom that at this time, her son does not need antibiotics since
bronchiolitis is caused by a virus. Instead, I would educate her on the importance of keeping his
temperature down, if it were to be 100.4F, with the Tylenol and then alternating with Ibuprofen,
keeping him hydrated, and fed without causing him undue respiratory stress. I would ask if she
has a nasal suction device, such as a bulb syringe and if she is comfortable using it to keep his
nasal passage and mouth clear of drainage.
Education to mom about hand hygiene with soap and water or hand sanitizer after
cleaning his face, nose, or changing his diaper. The importance of throwing away the tissues used
to keep his nose clean.
Discussion with mom about feeding techniques to reduce respiratory distress include
smaller amounts of food more frequently and keeping him hydrated with water. Limiting the
amount of milk, as milk tends to thicken mucosal drainage (Dr. L. Byrd, personal
communication, June 28, 2020).
Educating mom that the cough can last for 2-3 week.
Ensuring mom understands not to use traditional, cultural remedies as they can be more
harmful than helpful.
If he attends daycare, he should not return until after he no longer has a fever.
Avoid exposing him to cigarette smoke.
Educating mom on the signs of increased respiratory distress such as blue tinged lips,
increased effort with breathing, unable to eat or drink due to difficulty breathing. If any of these
happen, call 911.
HEALTH PROMOTION
A 14-month-old should have received the following vaccines per CDC (www.cdc.gov).
Hep B 3 doses
DTaP 3 doses
Hib 3-4 doses depending on the type ActHIB, Hiberix, and Pentacel 4 doses. PedvaxHIB
3 doses.
IPV 3 doses
Rotovirus 2-3 doses depending on the type. However the last dose would have to have
been given prior to 8months 1 day of age.
PCV 13 4 dose
MMR 1 dose
Varicella 1 dose
Hep A 1 dose
Next well child check will be at 15 months of age. If his vaccines are not up to date the
DTap, Hib, PCV 13, MMR, Varicella and Hep A can be given then.
ANTICIPATORY GUIDANCE
I would share with mom the Hagan, et al., (2017) 15-month anticipatory guidance which
indicates a 15 month children should be imitating scribbling, drinking from a cup, understanding
questions like “Where’s the ball? Or Where’s your blanket” and looking around for it, using 3 or
more words, squats to pick up objects, crawls up steps, runs, places items in a container and
removes them, and can mark with a crayon.
Sharing with mom that it is important to allow him to choose between two items such as
which shirt, pants, or shoes he wants to wear. Helping her understand stranger anxiety and
separation anxiety heightens and to help him understand it is okay and you will be back.
Continuing reading to him.
Speak slowly and clearly with clear instructions or descriptions as it helps with language
development.
Encourage a bedtime routine, with brushing his teeth as part of it and going to bed regardless if
he is tired. Reinforcing with mom the no bottles or sippy cups in bed.
As tantrums begin, try distraction techniques.
Praise him for good behavior and doing good things.
Use time-outs.
Car seat safety, heat safety, water/pool safety, gun safety, cleaning product safety, and choking
hazard safety reviewed with mom.
Follow up in 3-5 days if no improvement.
911 if he is respiratory distress
Engorn, B. and Flerlage, J. (2015). The Harriet Lane Handbook (20th ed.). Elsevier.
Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health
supervision of infants, children, and adolescents (4th ed.). American Academy of
Pediatrics.
Maaks, D., Starr, N., Brady, M., Gaylor, N., Driessnack, M & Dudestadt K. (Ed.). (2020). Burns’
Pediatric Primary Care (7th ed.). Elsevier.
Ralston, S.L., Liebethal, A.S., Meissner, H.C., Alverson, B., K., Baley, J.E., Gadomski, A.M., …
Herndanez-Cancio, S. (2014). Clinical practice guideline: The diagnosis, management,
and prevention of bronchiolitis. Pediatrics, 134(5), e1474-e1502. Retrieved from
http://pediatrics.aapublications.org/content/pediatrics/early/2014/10/21/peds.2014.2742.f
ull.pdf
Yu, J., Qian, S., Liu, C., Xiao, Y., Xu, T., Wang, Y., Su, H., Chen, L., Yuan, B., Wang, X., Xu,
B., Yang, Y., Shen, K., Xie, Z., Ren, L., & Wang, J. (2020). Viral etiology of life‐
threatening pediatric pneumonia: A matched case‐control study. Influenza & Other
Respiratory Viruses, 14(4), 452–459.
https://doi-org.ezp.waldenulibrary.org/10.1111/irv.12738
HPI: Miguel is a Latino 15-year-old male who presents for a sports physical. He is a healthy
adolescent with no complaints. He plays basketball.
PE: He is 6 feet 5 inches tall and weighs 198 pounds.
MS: You note long arms and long thin fingers. He has joint laxity in his wrists, shoulders, and
elbows
Response 1
As a pediatric provider seeing an above average, tall, 15-year-old male I too would
suspect Marfan syndrome. Gathering additional familial history and past medical history is
pertinent to accompany the physical exam. Additionally, as the provider, I too, would confirm
the diagnosis with genetic testing of fibrillin-1gen (FBN1), slit lamp examination for myopia,
and an echocardiogram as recommended by The Harriet Lane Handbook (Engorn and Flerlage,
2015). An additional test includes CT angiogram for more accurate measurements of the aorta.
Identifying the size of the aorta is necessary as Marfan syndrome causes enlarged aorta, therefore
leading to possible dissection or tearing, leading to death (Marfan, 2017). Until this 15-year-old
has completed all necessary testing, I would not clear him to play basketball or any other contact
sport, the risk of death is high if his aorta is enlarged.
A recent study found the diagnosis of Marfan is higher among males over females,
through-out the lifespan of patients, with the median age being 19 years old (Groth et al., 2015).
Therefore, it is important for all providers, not just pediatric providers, to be observant of Marfan
syndrome signs. Groth et al. (2015) shares Marfan syndrome is a known, life-threatening
disorder and data collected indicates many Marfan patients are not diagnosed until well after
their pediatric years. Therefore, all medical providers need to be observant and test the patient
with the diagnosis is suspected. The physician I work for, specifically mentions if the patient has
a family history or potential risk for Marfans. I thoroughly understand why, after this week’s
lesion.
If the testing results indicated the aorta was enlarged, what size would cause you to be
concerned and what your next step be?
Engorn, B. and Flerlage, J. (2015). The Harriet Lane Handbook (20th ed.). Elsevier.
Marfan syndrome- Patient-led movement spells brighter future for those with rare
condition.(2017). https://www.nhlbi.nih.gov/news/2017/marfan-syndrome-patient-ledmovement-spells-brighter-future-those-rare-condition
Groth, K. A., Hove, H., Kyhl, K., Folkestad, L., Gaustadnes, M., Vejlstrup, N., Stochholm, K.,
Østergaard, J. R., Andersen, N. H., & Gravholt, C. H. (2015). Prevalence, incidence, and
age at diagnosis in Marfan Syndrome. Orphanet Journal of Rare Diseases, 10(1), 1–10.
https://doi-org.ezp.waldenulibrary.org/10.1186/s13023-015-0369-8
 Explain how culture might impact the diagnosis, management, and follow-up care of
patients with the respiratory, cardiovascular, and/or genetic disorders your colleagues
discussed.
 Based on your personal and/or professional experiences, expand on your colleagues’
postings by providing additional insights or different perspectives.
Response 2
Cultural Impact
One thing that comes to my mind when I think of cultural impact on an adolescent,
particularly one entering the middle adolescent stage as defined by Hagan et al. (2017) is the
increased exposure, peer pressure, attempts to use, or misuse substances such as alcohol, tobacco
products, and illicit drugs. Dabbling in these increase the risk of injury and death (Hagan et al.,
2017). Additionally, data collected indicated adolescents exposed to parents who wrongly used
substances were affected with poor self-concept and were at higher risk of using as well (Kaur
and Jiwan, 2020). As a provider to an asthmatic adolescent smelling of cigarette, it is imperative
to discuss the anticipatory guidance on substance abuse and the effect on his diagnosis. Without
accusing them or point out who smokes, stressing the importance of avoiding exposure to
nicotine, cigarette smoke, or electronic plume in any setting is essential to his asthma being
under control.
Professional Insight
I like that you thought to inquire if the ICS had been helping prior to running out and
what activities had he been doing to bring on the need to use his SABA so often. This
information is important to drive the plan of care. An additional question I would direct toward
the parents would be if they knew he was out of his medication, did they notice any changes in
his respiratory functions, and lastly if financial concerns were related to not filling the
medication. If this were part of the issue, supplying a sample or providing information for an
assistance program would be beneficial.
I would also inquire if the patient has a peak flow meter at home. If yes, does he
understand how to use it, has he been using it daily and jotting down the readings, and does he
understand how it helps him with his asthma? The Asthma and Allergy Foundation of America
(www.aafa.org) is an excellent site to help patients and caregivers understand the importance of
peak flow. Educating the patient on daily peak flow measurements, prior to taking asthma
medications, helps to identify airway changes prior to a serious asthma attack. Reading the
readings are below 80 percent of personal best the predetermine asthma plan should be referred
to or a call to the office for guidance. Additionally, ensuring the parents and patient understand
the importance to the daily use of the ICS, how it helps to reduce asthma exacerbations, how the
SABA works, and avoiding triggers such as cigarette smoke, allergens, dust, and exercise (Maaks
et al., 2020) is required to provide the best care.
Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health
supervision of infants, children, and adolescents (4th ed.). American Academy of
Pediatrics
Kaur, S., & Jiwan, T. (2020). A Study to assess the effectiveness of psychosocial intervention on
self- concept of adolescents of substance using parents. Journal of Indian Association for
Child & Adolescent Mental Health, 16(2), 76–89.
Maaks, D., Starr, N., Brady, M., Gaylor, N., Driessnack, M & Dudestadt K. (Ed.). (2020). Burns’
Pediatric Primary Care (7th ed.). Elsevier.