Critical Thinking Case Studies is designed to test your problem-solving and decision-making abilities.
Instructions: Read the symptom(s) below. Then, outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the summary.
John is a 9-month-old, African-American boy presenting to the primary care clinic with his mother for his well-child check and a rash on his neck. His mother expressed concerns because the rash has been present for three months and will often drain fluid that looks like water. She denies any other complaints or recent illness for John. According to his mother, John's father had a similar rash when he was a child. John does not have any health problems and no scheduled daily medications. His mother reports that she has not given him any over-thecounter medications and has not used any skin creams.
History of Present Illness
John's mother reports that the rash has not changed in appearance over the past three months. John does not seem to be bothered by the rash. His mother reports that he does not scratch at it and has not been fussy. The area has always drained the clear liquid per his mother's report.
Past Medical History
John has been coming to this clinic since birth. His immunizations are up to date, and he has been seen once this year for cold symptoms. John has had the occasional cough and runny nose, but no other health illnesses according to his mother. His mother also denies any known drug or food allergies.
Development and Growth History
John's mother reports that she had an uncomplicated pregnancy and vaginal delivery. She received prenatal care and was 40 weeks pregnant at the time of the delivery. John has developed normally. He was able to sit-up at age 4 months, crawled at age 7 months, and is now pulling up, attempting to cruise along furniture. He is able to hold his own bottle and self-feed with finger foods.
Family and Social History
John's mother denies any family history of asthma, sickle cell disease, heart disease, or diabetes. John's paternal grandfather has eczema, but his mother denies any other paternal health problems or any significant maternal history. John lives with his mother, father, 5-year-old brother, and 3-year-old sister. He attends daycare five days a week. His mother works as a cosmetologist and his father works in construction.
According to his mother, John continues to take formula, 6 to 8 ounces every 4 to 6 hours, and eats baby food. His mother reports he drinks juice and eats table food on occasions. He gets rice cereal usually twice a day in his bottle. His mother also reports he eats well at daycare.
Physical Assessment Findings
General Appearance. John presents awake and alert. He appears wellhydrated and responds age-appropriately throughout the examination.
Vital Signs. Temp: 98.8, Height: 28 in, Weight: 9.09 kg, HR: 120, RR: 32, head circumference 46cm. John plotted at the 50th percentile for weight and age and 50th percentile for length and age.
HEENT. Head normocephalic, intact. Hair evenly distributed. PERRLA noted. Sclerae and corneas clear. Red reflex noted bilaterally. TMs noted clear bilaterally. Trachea noted midline. Neck: full ROM without resistance, no tenderness to touch. Mouth: moist mucosa membranes without lesions noted. Tongue intact without edema. No lymphadenopathy noted. Uvula midline and mobile.
Integumentary. Warm and dry to touch. A 1 cm x 1 cm papular lesion noted to the left side of the neck along the sternocleidomastoid muscle with clear discharge. No inflammation, no redness, no pus drainage, no tenderness noted.
Respiratory. Respirations even and unlabored. Breath sounds clear bilaterally. No increased work of breathing noted.
Cardiovascular. Regular, rate, and rhythm noted. S1 and S2 sounds noted. No murmurs or thrills noted. Less than 3-second cap refill noted. PMI noted at left midclavicular line over apex.
Abdomen. Abdomen soft and non-distended. No tenderness to touch noted. Abdominal reflex present.
Neurological. Speech (babbles) noted intact. Cranial nerves intact.
Musculoskeletal. Full ROM and symmetrical muscle strength noted in all extremities. No edema, no tenderness, no erythema noted over joints. Spine noted midline.
Genitalia. Tanner Stage I noted. Testes noted descended.
Anus. No lesions noted.
Pediatr Nurs. 2013;39(5):254-255. © 2013 Jannetti Publications, Inc.