history: Lamont lives at home with both parents and his 1‐year‐old sibling. The family has been in the United States for 2 years. They are in the United States so that Lamont’s father can study biology at a local university. His mother is currently not working because her visa does not allow her to work. The family has no pets. There are no smokers in the home.
Family medical history: Lamont’s mother (26 years old) and father (30 years old) both have sickle cell trait, but neither has a history of chronic medical conditions. Lamont’s 1‐year‐old sister also has sickle cell trait. His maternal grandmother (46 years old) has a history of hepatitis. His maternal grandfather (50 years old) has a history of tuberculosis (successfully treated before Lamont was born). Lamont’s paternal grandfather (51 years old) has no known history of health problems. His paternal grandmother (50 years old) has a history of malaria.
Medications: Lamont is not currently taking any over‐the‐counter, prescription, or herbal medications. He has no known allergies to medication, food, or the environment. He is up to date on required immunizations.
OBJECTIVE
Lamont’s vital signs are taken, and his weight in the office is 24 kg. His temperature is 37.5oC (temporal). He is alert, cooperative, and interactive. He appears well hydrated and well nourished.
Skin: His skin is clear of lesions. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and Lamont has good skin turgor on examination.
HEENT: Lamont is normocephalic. Red reflexes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. Lamont’s external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membranes. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Lamont’s mucous membranes are noted to be moist when examining his oropharynx. He has 20 teeth present. Both premolars on the lower, left side are noted to have visible caries. The gingival area surrounding those 2 teeth is erythematous and edematous. The area is tender to touch. There are no other lesions present in the oral cavity.
Neck: Supple and able to move in all directions without resistance. There is a 1‐cm diameter left, anterior cervical node present. The node is nonerythematous, mobile, and mildly tender to touch.
Respiratory: Respiratory rate is 20 breaths per minute, and lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiovascular: Heart rate is 92 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds throughout; soft and nontender. No evidence of hepatosplenomegaly.
Genitourinary: Normal uncircumcised male genitalia without erythema or lesions. His testes are descended bilaterally.
Neuromuscular: Good tone and full range of motion in all extremities, warm, and well‐perfused. Capillary refill is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Complete blood count___Erythrocyte sedimentation test___Dental X‐ray
2 What are the most likely differential diagnoses and why?___Gingivitis___Dental caries___Periodontitis
3 What is the plan of treatment, referral, and follow‐up care?
4 Does this patient’s psychosocial history affect how you might treat this case?
5 What if the patient lived in a rural setting?
6 Are there any demographic characteristics that might affect this case?
7 Are there any standardized guidelines that should be used to assess or treat this case?
Case 3.5 Abdominal Pain
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Four‐year‐old Jennifer presents to the office with a complaint of abdominal pain for 2 days. She is accompanied by her mother, Anat. Anat states that Jennifer’s pain is intermittent and is mainly on the left side of her abdomen. She states that the pain is sometimes worse after eating and that the pain is sometimes relieved by passing gas. Jennifer is unable to describe the quality of the pain, but Anat states that Jennifer will sometimes “double over” in pain. Jennifer has had no vomiting or diarrhea. She has had no cough or runny nose.
Diet: Jennifer’s nutrition history reveals that she eats bananas and rice almost daily. She drinks 4–5 cups of whole milk daily.
Elimination: She is voiding well with no complaints of dysuria. Jennifer has 2–3 bowel movements per week. Anat is unsure of the amount or consistency, since she rarely accompanies Jennifer into the bathroom.
Sleep: Jennifer sleeps approximately 10 hours at night. She has no problems falling asleep or staying asleep. Her sleep has not been interrupted by her abdominal pain.
Past medical history: Jennifer was born via cesarean section at 37 weeks’ gestation. Since being discharged at 4 days of age, she has had no emergency department visits or hospitalizations. Jennifer had bronchiolitis at 6 months of age but has had no injuries or illnesses since that time. Jennifer passed her developmental screening at her last well‐child visit. She currently attends prekindergarten and is doing well, according to Anat. She has no chronic illnesses and is not currently taking any medications.
Social history: Jennifer lives at home with both parents and a 2‐year‐old sibling. Her mother works as a nurse, and her father is a firefighter. The family has a pet chihuahua. There are no smokers in the home.
Family medical history: Jennifer’s mother (29 years old) and father (29 years old) are healthy and have no history of chronic medical conditions. Her 2‐year‐old sibling is healthy as well. Her maternal grandmother (52 years old) has a history of Crohn’s disease. Her maternal grandfather (54 years old) has a history of asthma. Jennifer’s paternal grandfather passed away at 47 years of age from stomach cancer. Her paternal grandmother (53 years old) has a history of obesity and Type 2 diabetes.
Medications: Jennifer is currently taking no over‐the‐counter, prescription, or herbal medications. She has no known allergies to medications, food, or the environment. She is up to date on required immunizations.
OBJECTIVE
Jennifer’s vital signs are taken, and her weight in the office today is 27 kg. Her temperature is 37°C (temporal). She is alert, cooperative, and interactive. She appears well hydrated and well nourished.
Skin:
