Case Study 2
Jacob is a 1.5 week old brought in by his distressed mother. While changing his diaper last night, she noted that his penis was edematous and erythematous. He has been crying and fussy. Per mom, no other complaints. He’s been breastfeeding every 1-2 hours without any issues.
PE: Stable VS and growth patterns. Essentially a normal examination with the exception of a slightly erythematous and edematous glans penis with retracted prepuce.
Post an analysis of your assigned case by responding to the following:
•What additional questions will you ask?
•Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
•What additional examinations or diagnostic tests, if any will you conduct?
•What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
•What is your most likely diagnosis and why?
•How will you treat this child?
•Provide medication treatment and symptomatic care.
•Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
•Patient Education, Health Promotion & Anticipatory guidance:
•Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
•Include any socio-cultural barriers that might impact the treatment and management plans.
•Health Promotion:
•What immunizations should this child have had?
•Based on the child’s age, when is the next well visit?
•At the next well visit, what are the next set of immunizations?
•What additional anticipatory guidance should be provided today?
Primary Diagnosis Paraphimosis then please explain why you think this should be it with reference and then come up with 3 differential diagnosis and supporting documentation of why should not be each of those 3. Please make sure that all questions from instructions are answered.
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.