Toddler Nurse Maid Elbow: History and Physical -Assignment 1 Solution

Toddler Nurse Maid Elbow: History and Physical Assignment Solution

Instructions

Students are required to do a full history and physical write up for patients encountered during practicum. A write-up must be conducted for (1) pediatric patient chosen from each of the following age groups: Infant, Toddler, Preschooler, School Age or Adolescent. These write-ups should include a complete history and physical, along with differential diagnosis, plan of care, billing codes, medications prescribed, etc. Each H&P should be submitted to a separate drop box with a file name indicating the age group examined for the submitted H&P. Example: Wallace HandP Toddler.docx. There is a sample H&P that students are welcome to use for formatting available in the resources section of Canvas. See attached rubric for required elements and points breakdown.

Solution

Provider:                                                        Patient: W.K.

Date of Service: 15/4/2022                            Date of birth: March 19, 2019

Time of Service: 0915                                   Age: 37 months

Race/Ethnicity: Caucasian                            Gender: Male

Insurance: Blue Cross Blue Shield PPO

Allergies: NKDA

Medication: No prescribed medications. The mother states she has been giving him OTC Children’s Tylenol 12.5ml every four hours as required for his reoccurring fever

Chief Complaint: Patient presents with right elbow pain, which has worsened in the last two days

Historian: Mother

History of Present Illness: Patient (A.T.) presents today for an evaluation of right elbow pain which has worsened in the last two days. The injury occurred while being lifted/pulled. Onset of symptoms was three days ago. Mother reports pain is 6/10 in severity.

Mother reports pain and symptoms of swelling, bruising. Symptomatic treatment prior to arrival includes ice, Tylenol/Ibuprofen. Mother reports frequent crying during the night, and when the patient is put to sleep. Mother admits patient wakes up frequently since the onset of symptoms. Patient also struggles to eat or hold the spoon when eating. Mother reports patient crying when she tries to feed him.

Past Medical History (PMH):

Allergies: NKDA

Current Medications: No prescribed medications. The mother provides that she has been giving the patient OTC Children’s Tylenol 12.5ml every 4 hours for his reoccurring fever.

Age/Health Status: 37 months/ No chronic health problems

Appropriate Immunization Status: Up to date on all vaccines; Mother states the patient received a flu vaccine last year and will receive another this year at his primary physician’s office this fall.

Dates of Illness during Childhood: N/A

Injuries: No significant injuries requiring hospitalization or medication intervention.

Hospitalizations: No hospitalizations

Health Maintenance and Health Promotion:

• Mother states good compliance with yearly check-ups with the pediatrician and has an appointment for September 15^th
• Dental visit every 6 months; brushes at least once a day. No cavities at the last appointment, which was 2 months ago
• The mother states frequent handwashing
• Well balanced diet
• The mother states he is giving the patient daily multivitamin
• The mother reports no lead exposure risks
• The mother states the patient is very active; physical activity for at least 2 hours daily. The patient likes to play with balls, swim, and ride toys outside. Allowed to watch T.V. daily for a maximum of two hours.
• Mother states patient rides in an appropriate car/booster seat. Home pool has a cover, and the entry gate is locked. The patient swims under his parents’ supervision. There are no guns in the home, all medications are locked away, and the patient does not know the location of the keys.

Family History (F.H.): The patient is the second born and has a sister. Mother is 32 years old, and the father is 34 years old. Older sister is 7 years old and has no significant health issues. Mother reports no health problems for herself. Mother reports father had a recent diagnosis of ulcers.

Maternal grandmother is 58 years old and has suffered from obesity for the past 10 years. Maternal grandfather is 60 years old and has hypertension. Paternal grandmother is 64 and has a history of breast cancer with a bilateral mastectomy but is now in remission. Paternal grandfather is 65 years old and has diabetes mellitus. Maternal aunt (age 24) and paternal uncle (age 26) have no significant past medical history.

Social History: Patient will be in preschool this school year. He is active and always plays outside with other kids and his sister when she returns from school. Mother states that both parents do not smoke, but the father drinks alcohol occasionally. Patient does not drink caffeine. He is allowed to watch T.V. for a maximum of 2 hours daily. Mother reports that the patient has struggled to play or hold his toys using his right arm since the onset of symptoms.

Growth and Development:     

Physical Growth: Height is appropriate, but weight is not appropriate with growth curves per CDC Guidelines (See Appendix B). The patient’s BMI is 18.1, which is not within the healthy BMI range for this patient’s age group.

Motor: Fine and gross motor skills are WNL for the patient’s age.

Cognitive: The patient’s cognitive function is WNL for the patient’s age.

Verbal: Patient with normal communication for age.

Social: Patient’s social development is within normal parameters for his age.

Personality: Patient is intense, sensitive, active, and easily distractible.

School: Patient does not attend preschool.

Review of Symptoms:

Constitutional symptoms: Mother reports fever, fatigue, decreased appetite, and difficulty sleeping. Denies malaise, night sweats, unexplained weight loss, or weight gain.

Eyes: Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. No corrective lenses. Mother states the date of the last eye exam was in September of 2021, and exam results were reported normal (20/20 vision).

Ears, Nose, Mouth, and Throat: Mother reports occasional sore throat and ear pressure. Denies throat pain when he swallows or rawness in his throat. Denies headaches, hoarseness, vertigo, sinus problems, epistaxis, dental problems, oral lesions, hearing changes, and nasal congestion. The date of the last dental visit was about 2 months ago.

Cardiovascular: Mother states the patient is very active and likes to play outside with friends and his sister when she comes back from school. He participates in physical activity for at least two hours daily. Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema.

Respiratory: Mother reports cough that started 2 days ago. Denies history of respiratory infections, SOB, wheezing, difficulty breathing, exposure to secondary smoke, T.B., hemoptysis.

Gastrointestinal: Mother reports that the patient is struggling to eat and seems to have a decreased appetite since the onset of symptoms. Denies pain when he is swallowing; dysphagia. Denies reflux, pyrosis, bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids. Mother states she tries to prepare healthy, well-balanced meals and feed the patient.  

Genitourinary: Mother denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, and history of stones.

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Musculoskeletal: Mother reports joint/elbow pain and tenderness, and the arm is held at the side motionless. Mother denies back pain, muscle pain or cramps, neck pain or stiffness, and changes in ROM. Mother states patient is active for at least two hours every day. He wears his seatbelt.

Integumentary: Mother denies itching, urticaria, hives, nail deformities, hair loss, moles, open areas, bruising, and skin changes. The mother states she applies sunscreen while outside and inspects his skin always for any changes.

Neurologic: Mother denies headache, weakness, numbness, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, or paresthesia.

Psychiatric: Mother denies nightmares, mood changes, anxiety, depression, nervousness, insomnia, suicidal thoughts, exposure to violence, or excessive anger. Mother states the patient has had difficulty sleeping since the onset of symptoms.

Endocrine: Mother denies cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, changes in hat or glove size, use of hormonal therapy.

Hematologic/lymphatic: Mother denies unusual bleeding or bruising, lymph node enlargement or tenderness, fatigue, history of anemia, and blood transfusions.

Allergic/immunologic: Mother denies seasonal allergies, allergy testing, exposure to blood or body fluids, use of steroids, or immunosuppression in self or family.

Developmental: Denies delay of gross or fine motor skills or cognitive development.

Physical Exam:

Weight: 20.3 kg

Height: 106 cm

BMI: 18.1

Vital Signs: Temperature 98.6; BP-100/68; HR 74; RR 20; O2 sat-100%

General Appearance: healthy-appearing, well-nourished, and well-developed.

Level of Distress: NAD.

Ambulation: ambulating normally.

Eyes: sclera white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular movements are intact.

Ears: external appearance normal, no lesions, redness, or swelling; on otoscope exam, tympanic membranes clear, no redness, fluid, or bulging identified. Hearing is intact.

Nose: The nose’s appearance is normal, with no mucous, inflammation, or lesions. Nares patent. Septum is midline.

Mouth: pink, moist mucous membranes. No missing or decayed teeth.

Throat: Soft and hard palates are intact. No lesions or pharyngitis were noted on examination: no ulcers, masses, or exudate were present.

Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs. Carotid Arteries: normal pulses bilaterally, no bruits present Pedal Pulses: 2+ bilaterally.

Extremities: no cyanosis, clubbing, or edema, less than 2-second refill noted. Patient is warm and dry, with no edema or cyanosis noted.

Pulmonary/Thorax: Even and unlabored. Clear to auscultation bilaterally with no wheezes, rales, or rhonchi. Breath sounds are clear throughout all lung fields.

Gastrointestinal: abdomen soft and non-tender to palpation, non-distended. No rigidity or guarding, no masses present, bowel sounds present in all 4 quadrants.

Genitourinary: No bladder distention, suprapubic pain, or CVA tenderness.

Musculoskeletal: Arm is held motionless at the side, radial head tender, and audible snap heard with radial head subluxation. Elbow extended. Joint stability is normal in all extremities. Slight tenderness to palpation

Integument/Lymphatic:

Inspection: No scaling or breaks on skin, face, neck, or arms.

General palpation: no skin or subcutaneous tissue masses present, no tenderness, skin turgor normal

Face: no rash, lesion, or discoloration present

Lower Extremities: no rash, lesion, or discoloration present

Upper Extremities: no rash, lesion, or discoloration present

Neurologic: Grossly oriented x3, communication ability within normal limits, attention, and concentration normal. Sensation intact to light touch, gait within normal limits

Psychiatric: Judgment and insight intact, rate of thoughts normal and logical. Pleasant, calm, and cooperative. Patient appears distressed.

Hematologic/immunologic: Lymph nodes not palpable, no tenderness or masses present, no bruising

Back: Spine is WNL with no curvature, deformities, or lesions.

Stages of Development:

Erickson’s Stage of Psychosocial Development: Initiative vs. Guilt

The patient demonstrates appropriate behavior for this stage of development as he is curious about the world around him. He plans activities, makes up games, and initiates play with others. He copies his parents and other children. The patient often oversteps the boundaries in his forcefulness, forcing the parent to restrict activities.

Piaget’s Stage of Cognitive Development: Preoperational Period

The patient exhibits behavior appropriate for this stage of development in that he is egocentric, thinks about things symbolically, and his language is more mature. The patient engages in make-believe, is more imaginative, and can understand the difference between the past and the present.

Motor Sensory Development: WNL; Patient can ambulate without assistance. Reports no muscle weakness. Patient reports difficulties moving his right arm.

Developmental: Patient’s development is appropriate for his chronological age.

Elbow Exam:  Inspection: No bony or soft tissue deformity. Slight soft tissue swelling. 

Tests for laxity: no anterior, posterior laxity. Gross neurovascular exam intact. Range of motion normal. 2+ radial pulse. 

Assessment:

1. 37 months old male patient with no significant medical history, normal growth and development, presenting with right arm pain. 

Presumptive Diagnosis

1. Nursemaid’s elbow- S53.033A
2. Septic joint- M00. 80
3. Muscular strain- M62. 6
4. Fracture- S52. 501A

Differential Diagnoses

1. Radial Head Fracture or Complete Dislocation– S53.004A

Patient should indicate supporting the weight of the injured arm with the other arm, unwillingness to use the injured arm, and unwillingness to stretch fully or flex the injured arm (Imani & Graber, 2019). Wrist, arm, or elbow pain is usually poorly localized, generally dull, vague, and aching.

• Posterior Elbow Dislocation– S53.124A

Patient presents with severe elbow pain, swelling, and inability to bend the injured arm (Waymack & An, 2021). In extreme cases, patients can have lost feeling in the arm or lose pulse in the wrist.

• Condylar and Supracondylar Fractures of the Distal Humerus– S42. 413A

The patient presents with severe elbow pain, forearm pain, swelling in the elbow, numbness in the hand, loss of elbow function, color and warmth in the fingers or hand, and noticeable deformity around the elbow or arm (Hope & Varacallo, 2020).

• Buckle Fracture of the Radius or Ulna– S52. 621A

Patient presents with pain, swelling, and tenderness in the injured arm, bruising or dislocation, and a deformity or bump that is not typical of the patient’s body (Patel et al., 2021).

Confirmed Diagnosis: Toddler Nurse Maid Elbow (S53.033A); Given the mechanism, the nursemaid’s elbow was confirmed. The elbow was manipulated using the hyper pronation technique, and subluxation was reduced. The patient was then observed for some time and was using her arm normally.

Given the return to normal function, x-rays are not indicated. No other injuries, no concern at this time for child abuse. Advised caregiver to follow up with primary care provider as needed. Return to the emergency department urgently if new or worsening symptoms develop.

Impression: Nursemaid’s elbow

Plan:

1. Discharge from Emergency Department
2. No activity restrictions
3. Tylenol for general discomfort

Generic name: acetaminophen

Brand names: Tylenol Ext, Little Fevers Children’s Fever/Pain Reliever, Little Fevers Infant Fever/Pain Reliever

Indication: Temporarily relieves minor aches and pains due to headache, backache, the common cold, minor pain of arthritis, toothache, premenstrual and menstrual cramps, and muscular aches, and temporarily reduces fever (Gerriets et al., 2021).

MOA: Tylenol belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). MOA is not well known, but it may minimize the production of prostaglandins in the brain (Gerriets et al., 2021). Prostaglandins are chemicals that lead to inflammation and swelling.

Dose: 12.5 ml every 4 hours or 5 doses in 24 hours

Prices: The lowest price is around $1.35

            The average retail price is $4.02

Contradictions: Tylenol contradictions include hypersensitivity to acetaminophen, severe hepatic impairment, severe active hepatic disease

• Follow-up if pain persists in 3-4 days with the primary care provider
• Informed to return to Emergency Department if has new or worsening symptoms.
• Monitoring for desired clinical effects and pain relief

Billing Codes:

            ICD Codes:

1. Nursemaid’s elbow- S53.033A
   1. Radial head fracture or complete dislocation- S53.004A
   1. Posterior elbow dislocation- S53.124A
   1. Condylar and supracondylar fractures of the distal humerus- S42. 413A
   1. Buckle fracture of the radius or ulna- S52. 621A

Education:

1. Call the office if the pain returns or becomes more severe, or the patient still indicates difficulties moving the arm.
2. Report immediately in case of adverse effects like skin rash or hypersensitivity reactions.
3. Monitor return to regular activity and continuous use of the right arm.

Evidence-Based Rationale

Nursemaid’s elbow is a common injury among kids, particularly between ages 1-3. It occurs when the radial head slips under the annular ligament leading to pain and inability to supinate the forearm. Nursemaids’lids represent 20% of upper extremity injuries in kids, and it occurs less as children develop above the age of 5 years (Nardi & Schaefer, 2020).

Caregivers/parents often report no known trauma because the incident can occur during a fall, upward pulling, lifting, or swinging. The physical exam might indicate that the child is nervous and appears to be supporting the affected arm with the opposite arm or laying it at the side motionless. The patient is reluctant to move the arm and appears distressed during physical examination.

There is tenderness at the radial head, and the patient resists forearm flexion, extension, supination, or pronation (Nardi & Schaefer, 2020). There are no signs of ecchymosis, erythema, edema, or trauma. Treatment involves closed reduction, which can be painful as the annular ligament reduces to its appropriate position.

References

Gerriets, V., Anderson, J., & Nappe, T. M. (2021). Acetaminophen. StatPearls [Internet].

Hope, N., & Varacallo, M. (2020). Supracondylar Humerus Fractures. In StatPearls [Internet]. StatPearls Publishing.

Imani, G., & Graber, M. (2019). Radial Head Dislocation. StatPearls [Internet].

Nardi, N. M., & Schaefer, T. J. (2020). Nursemaid elbow. In StatPearls [Internet]. StatPearls Publishing.

Patel, D. S., Statuta, S. M., & Ahmed, N. (2021). Common Fractures of the Radius and Ulna. American family physician, 103(6), 345–354.

Waymack, J. R., & An, J. (2021). Posterior Elbow Dislocation. StatPearls [Internet].

Appendix A

W.K. Family Medical History Genogram

Appendix B

Growth Chart

https://www.cdc.gov/growthcharts/data/set1clinical/cj41l021.pdf

Appendix C

BMI Calculation

https://www.cdc.gov/healthyweight/bmi/calculator.html

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