father works as a construction worker. The family has no pets. There are no smokers in the home.
Diet: Jair eats a balanced diet of table foods. He is transitioning from formula to whole milk. He takes a daily multivitamin.
Elimination: 4–6 wet diapers daily with 1 bowel movement.
Sleep: Takes one 2‐hour nap daily and sleeps 12 hours at night.
Family medical history: Paternal grandfather (age 54): healthy; paternal grandmother (age 53): hypertension; maternal grandfather (age 46): hypothyroidism; MGM (age 44): Type 2 diabetes; mother (age 18): asthma; father (age 18): healthy.
Medications: Currently taking no prescription, herbal, or over‐the‐counter medications.
Immunizations: Up to date.
Allergies: No known allergies to food, medications, or environment.
OBJECTIVE
Vital signs: Weight: 10 kg; length: 84 cm; temperature: 37°C (axillary).
General: Alert; well nourished; well hydrated; interactive.
Skin: Right side of forehead with ecchymosis and a 2 cm abrasion; no other lesions noted. No cyanosis of lips, nails, or skin; no diaphoresis noted; good skin turgor.
Head: Normocephalic; anterior fontanel is open and flat (1 cm × 1 cm).
Eyes: Red reflexes present bilaterally; pupils equal, round, and reactive to light; no discharge noted.
Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex.
Nose: Both nostrils are patent; no discharge.
Oropharynx: Mucous membranes are moist; 4 teeth are present; no lesions.
Neck: Supple; no nodes.
Respiratory: RR = 24; clear in all lobes; no adventitious sounds noted; no retractions; no deformities of the thoracic cage noted.
Cardiac/Peripheral vascular: HR = 100; regular rhythm. No murmur noted.
Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly.
Genitourinary: Normal circumcised male genitalia; testes descended bilaterally.
Back: Spine straight.
Ext/Musculoskeletal: Left arm with limited range of motion and tenderness to touch over left clavicle and left humerus. Both tender areas are slightly swollen and erythematous. Full range of motion of all other extremities; warm and well perfused; capillary refill < 3 seconds in all extremities.
Neurologic: Good strength and tone.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Radiograph of left arm/clavicle___CBC___Metabolic panel
2 What is the most likely differential diagnosis and why?___Fracture of left arm/clavicle to accidental fall___Physical abuse___Osteogenesis imperfecta
3 What is the plan for treatment, referral, and follow‐up care?
4 Are there any referrals needed?
5 Does the patient’s psychosocial history impact how you might treat him?
Case 4.8 Nightmares
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Six‐year‐old Daniel presents to the office with his mother, Donna, with complaints of frequent nightmares. Donna states that Daniel will be asleep and will suddenly sit upright with his eyes open and start to scream loudly. She says that Daniel looks terrified and that he sweats and breathes fast during these episodes. Donna says that while Daniel is screaming, she is unable to wake, console, or comfort him. The screaming episodes typically last about 5 minutes each and happen 3–4 times weekly. Donna states that after the screaming stops, Daniel returns to sleep and does not remember the screaming episodes when he awakens in the morning. Daniel does not have any problems falling asleep. He sleeps approximately 10 hours each night but does not have a set bedtime or a regular bedtime routine. He sleeps in his own bed and shares a room with his younger brother.
Diet: Balanced diet with sufficient sources of dairy, protein, fruits, and vegetables.
Elimination: Daniel is voiding well with no complaints of dysuria. He has 1 bowel movement daily and denies constipation or diarrhea.
Past medical history: Born via vaginal birth at 40 weeks’ gestation. The mother’s pregnancy was without problems. She had no infections, falls, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. There were no problems for Daniel during his neonatal period. Since birth, he has had no injuries or illnesses requiring visits to the emergency department. He has no chronic illnesses.
Family history: Daniel’s mother (27 years old) and father (26 years old) are both healthy and have no history of chronic medical conditions. His 3‐year‐old sibling also has no history of chronic medical conditions. His maternal grandmother (54 years old) has a history of asthma. His maternal grandfather (55 years old) has a history of high cholesterol. Daniel’s paternal grandmother (52 years old) has a history of hypertension. His paternal grandfather (52 years old) has a history of hypertension and had a stroke at age 47 years.
Social history: Daniel lives at home with his mother, paternal grandmother, paternal uncle, and his younger brother (3 years old). His mother works as a restaurant waitress. Daniel’s father is incarcerated. The family has no pets. There are no smokers in the home.
Medications: Daniel 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 for required immunizations.
OBJECTIVE
General: Alert, cooperative, and active; appears well hydrated and well nourished.
Vital signs: Weight in the office was 28 kg. Temperature was 36.9°C (temporal).
HEENT: Normocephalic. Red reflexes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted; external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examination,
