Diagnostic Reasoning
Running Head: DIAGNOSTIC REASONING AND CLINICAL DECISION
Diagnostic Reasoning and Clinical Decision Making Analysis Paper
N547: Infant, Child and Adolescent Health: Management of Common Illness
February 22, 2005
Caroline L. Derrick, RN, BSN
University of Michigan
Ann Arbor, MI
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Diagnostic Reasoning
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The following case example is of a 3 year old African American male referred to by the
initials of J.J. An established patient of Pontiac Osteopathic Hospital (POH) Children’s
Health Center, J.J. was seen in the office for acute exacerbation of chronic atopic
dermatitis (eczema).
Socio-Demographic Data
J.J. was brought to the office by his 23 year old mother, and accompanied by his one year
old sister. J.J. currently lives with his mother and younger sister in the home of his
maternal grandmother in Pontiac, Michigan. J.J.’s mother has completed a high school
education and recently was hired for a full time day shift at a local fast food franchise,
earning $6.00 per hour. During the daytime hours while his mother is at work, J.J. and his
younger sister are supervised by his grandmother. Once his mother is home, J.J.’s
grandmother then leaves for work. J.J.’s biological father has no contact with J.J or his
mother and has not since the child’s birth.
At the time of the visit, J.J was not covered by health insurance. His mother had
worked multiple jobs since his birth and only recently accepted her new position. Both
the Pediatrician and Nurse Practitioner at the POH clinic had previously given J.J.’s
mother the application for MIChild, an insurance plan for qualifying children in the state
of Michigan; however the application had never been completed. During the visit, J.J’s
mother was re counseled regarding the importance of applying for such medical
insurance, especially with J.J.’s exacerbations of eczema.
Diagnostic Reasoning
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Presenting Complaint/Problem/Issue:
J.J. was brought into the office because his mother and grandmother had observed him
walking with a limp for two days and had noted an exacerbation of acute atopic
dermatitis on his feet for two weeks.
History:
J.J.’s mother had explained that two days prior, J.J. had been playing in the living room
when suddenly, she heard J.J. scream and begin to cry. When she ran into the room to see
why J.J. was upset, she found him sitting on the floor, holding his left leg. J.J. and his
mother deny any trauma to the leg, and his mother denies hearing any loud noises or falls
from the next room. His mother reports than on examination of the limb, the skin was
intact and no signs of assault such as erythema, bruising, edema or insect bites were
visible. For the remainder of that day and the next, J.J. began and continued to walk with
a “limp”. No medication was administered to the child and his mother denies any febrile
state but was able to recall a slight palpable temperature two days later. J.J.’s mother
reports that his activity and appetite had decreased, secondary to the left leg limp, and she
had noted that J.J. was more irritable. She reports encouraging fluids and a “normal” fluid
intake of approximately four, six-ounce cups of juice/day. J.J.’s mother denies any
disturbance in the child’s sleeping patterns, recent infections. Mother does report
increased scratching of lower extremities and attempts to keep the child’s skin covered to
prevent further skin damage.
Allergy: PCN- hives
Family History: Unremarkable, atopic dermatitis thought to be on paternal side of family
Diagnostic Reasoning
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Psychosocial Issues: Multiple acute exacerbations of chronic atopic dermatitis per year,
child not enrolled in MIChild insurance program despite mother’s awareness of
eligibility. No contact with biological father.
Social: Lives with mother, younger sister, grandmother. No pets or smoking in the house
Environmental: Lives in an “older” home, gas stove, heat. One fire alarm checked every
three months, no carbon monoxide detector. Child does not have a bicycle or any use for
a helmet, sits in a child car seat facing forward in the rear of the vehicle. Child shares a
bedroom with his mother and younger sister. Family shares one vehicle.
Immunizations: Although the visit was focused on the acute problem, his medical record
indicated the J.J. was current in all of his immunizations and had tested negative for lead
at 15 months of age.
Review Of Systems (ROS):
All systems were unremarkable with the exception of integument.
Integument: J.J was diagnosed with atopic dermatitis (eczema) at six months of age.
Primarily located on his face, bilateral lower extremities and feet, the eczema has been
controlled primarily with a thin layer of Elidel 1% cream dosed BID. However, J.J.’s
mother reports running out of the samples of Elidel cream that were given to her on J.J.’s
last visit, a few months prior. The supply had been depleted for approximately one
month, however she reports that the eczema was under control and had planned to call the
clinic for more samples when she had the chance. Since his diagnosis, J.J has experienced
multiple acute exacerbations of atopic dermatitis, sometimes requiring low to moderate
dose steroid creams.
Diagnostic Reasoning
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Physical Assessment Data (Objective):
3 year old African American male, sitting on the exam table, no apparent distress. Child
is dressed appropriately for season, clothing appear slightly weathered, no malodor;
behavior is appropriate for developmental age. Child appears shy, child attempting to
hide behind mother.
A febrile
Physical examination unremarkable with exception of the following
Neurological: Difficult to assess secondary to cooperation of child, CN II-XII intact
HEENT: Unremarkable; Head normocephalic, no lesions, facial eczema minimal bilateral
cheeks; strep screen negative (will refer to this later in paper)
Lymph: no nodes palpable
Cardiac: S1 S2 RRR no murmur
Lungs: no wheezing, CTA
Integument: Bilateral lower extremities with flaking skin, extending to bilateral feet.
Patchy areas of intact skin, scant dried blood/crusting yellow in color on anterior surface
of feet. Posterior or dorsal/plantar surfaces of bilateral feet unaffected. Bilaterally,
extremities warm to touch, trace edema, capillary refill < 2 seconds. Dorsalis pedis and
posterior tibial pulses +3 bilaterally.
Musculoskeletal: No abnormalities noted bilateral upper extremities. Full ROM and
strength +5/5 bilateral upper and lower extremities. Gait altered with a limp on the left
leg. Able to invert and evert, dorseflex and plantarflex bilateral feet. Negative
Trendelenberg’s sign; no evidence of leg shortening as evidenced by equal measurement
of bilateral anterior superior spine of the ilium to the medial melleoli. Able to abduct
Diagnostic Reasoning
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bilateral lower extremities, painful adduction secondary to large, irregular mass located
on the posterior and medial left thigh. The area measured approximately 5 inches long x 2
inches wide and was flush with the surrounding skin tone. Skin surrounding the area was
intact, no evidence of trauma, ecchymosis, bleeding, insect bites. Area was solid, firm,
immobile, warm to touch and produced pain with palpation. No joints were affected.
Differential Diagnoses:
I. Cellulitis (left posterior/medial thigh) (Burns et. al, 2004)
II. Erythema Nodosa (Ter Poorten & Thiers, 2002).
III. Acute exacerbation of chronic atopic dermatitis (Jones, 2003)
Diagnostic Reasoning/Clinical Problem Solving
Through the diagnostic reasoning process, the following characteristics of each
diagnosis were considered in order to narrow the diagnosis.
Erythema Nodosum (EN) is the most common form of panniculitis and is
characterized by an inflammatory process in the subcutaneous tissue secondary to a
reaction to a variety of causes such as: beta-streptococcal upper respiratory tract infection
(most common cause in children), other bacterial infections, drugs such as sulfonamides,
oral contraceptives and bromides; inflammatory bowel disease, pregnancy, autoimmune
diseases, malignant diseases and sarcoidosis. The incidence and prevalence in the United
States is unknown, however females age 20-30 are predominantly affected. In children,
EN occurs equally in both genders. On examination, erythema nodosum is characterized
by tender, deep but raised, brightly erythematous nodules occurring most often on the
extensor surfaces of the distal lower extremities. Facial, forearm and thigh involvement
may occur. The nodules are usually 1-15cm in diameter. Associated symptoms may be
Diagnostic Reasoning
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systemic such as fever, chills, malaise, arthralgias, myalgias and a possible sore throat or
upper respiratory infection. The disease may last several weeks, with new nodules
appearing as old nodules resolve. As a nodule resolves, the skin takes on the appearance
of a bruise (erythemia contusiformis). Bedrest and support stockings help with symptom
management as are anti-inflammatory agents. All nodules usually resolve spontaneously
within 4-6 weeks with no reoccurrence in otherwise healthy populations. Lab tests
include elevated erythrocyte sedimentation rate (ESR), mild leukocytosis, a throat
culture, however the culture may be negative by the time a nodule presents. Deep skin
biopsy is rare. (Ter Poorten &Thiers, 2002).
After discussing the situation with the Pediatrician and Pediatric Nurse
Practitioner (PNP), it was decided to obtain an ESR and CBC, although results would be
pending for two days. A rapid strep test was obtained in the office and was negative. The
Pediatrician and PNP did not feel that a throat culture was needed at this time and we felt
as though the diagnosis of EN could be safely ruled out secondary to atypical
presentation of the thigh, the absence of multiple nodules, ecchymosis and other involved
areas. Lastly, the mass was measured at approximately 5cm x 2cm, much larger than the
typical nodule found in EN.
Acute Atopic Dermatitis is the most common form of a chronic pruritic
eczematous condition affecting characteristic sites such as the face (in infants), scalp,
trunk and exterior extremity surfaces. 80% of AD cases present before the age of five
years old. Characteristics of AD lesions vary according to stage. Mild to moderate lesions
are characterized by dry skin and light scaling, secondary to the patient scratching the
area. Acute lesions may have increased erythema and small vesicles may be present. In
Diagnostic Reasoning
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chronic cases of AD, thickening of the scaling may be present secondary to scratching.
Furthermore, due to a disruption in the skin as a barrier, patients with AD are more
susceptible to infections (Jones, 2003).
According to the diagnostic criteria of AD, J.J. has previously fit the criteria due
to: pruritis, family history, chronic relapse, early age of onset, facial involvement and
foot dermatitis. Through consulting with the Pediatrician and PNP, J.J was presenting
with an acute presentation of chronic atopic dermatitis, however, this was not his primary
diagnosis. Due to the tender mass found on his left thigh, it was hypothesized that a
cellulitis had formed secondary to an infection that was introduced through the open
areas of skin, resulting from chronic atopic dermatitis. It is known that in AD, serum IgE
levels tend to be elevated (Jones, 2003); however we found this test to be redundant
based on J.J’s already established history of AD and recurrent presentation. Although this
diagnosis could not be entirely ruled out, it was secondary to and the causative factor of
the primary diagnosis of cellulitis.
Cellulitis is a localized bacterial infection commonly involving the dermis and
subcutaneous layers of the skin, most likely resulting from a disturbance in the skin
surface. The most common invading bacteria is Streptococci, however H. influenzae and
S. aureus may be present. Clinical findings coincide with the findings noted in J.J.’s
assessment: previous skin disruption, fever, malaise, irritability, decreased appetite; Other
common findings such as recent sore throat or URI, anal pruritis, blood streaked stools
and stool retention were not found (Burns, et al., 2004). A CBC obtained for the purpose
to rule out EN could also aid in the diagnosis of cellulitis. At the time of the visit, the
child did not appear to be toxic so blood cultures were not obtained. Blood cultures are
Diagnostic Reasoning
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not recommended unless H. Influenza is the suspected organism or the child appears
toxic (Burns, et. al, 2004).
Primary Diagnosis
I.
Cellulitis- Left posterior/medial thigh (Burns et al., 2004)
Nursing Diagnosis
Impaired Skin Integrity r/t inflammation of dermal-epidermal junctions secondary to
bacterial infection as evidenced by left medial/posterior thigh cellulitis (Carpenito, 1999).
Management Plan
Medication
Immediate antibiotic intervention is necessary with significant infection (Burns et al.,
2004). Due to the fact that there was a concern regarding compliance, an initial dose of
Ceftriaxone 50mg/kg IM was administered in the clinic. The patient was sent home with
a prescription for Cephalexin 50mg/kg/day divided QID PO x 10 days (Burns et al.,
2004). Elidel 1% cream was also applied to J.J.s legs at the clinic.
Follow Up
The patient was to return to the clinic in 24 hours for reassessment. The literature
suggests that the child return to the office daily until the child is recovering (Burns, et al,
2004). However, due to financial constraints and the mother’s obligation to work, this
would not be feasible for this family. This issue was addressed with the Pediatrician and
PNP. I felt as though the cellulitis was invasive and that if the mother were to be
noncompliant with the medication, the condition might worsen. In my clinical judgment,
it would be safer for the child to be admitted to the hospital, ensuring proper antibiotic
treatment. After thoughtful consideration and debate, it was decided that although a
Diagnostic Reasoning 10
history of noncompliance can not be ignored, the child was not currently in a toxic state
and if treated aggressively and appropriately, a costly hospitalization for a non-insured
family may be avoided. It was decided at the end of antibiotic therapy, blood cultures
would be obtained to ensure a cure.
Education
The mother was thoroughly counseled on the condition and importance of compliance
with antibiotic therapy. Potential for further infection and sepsis were discussed and the
mother expressed a verbal understanding. She was given a one month sample of Elidel
1% cream and encouraged to call before she has used all of the samples to ensure a
timely replenishment. The mother was also counseled on applying for MIChild insurance
for her two children and given applications once again. It was understood that the child
was to return to the office in the morning for reassessment. The mother was also
instructed to return to the nearest emergency room if signs of worsening infection should
occur such as fever >102, increased pain, swelling, redness, inability to ambulate,
lethargy.
Evaluation and Follow Up of Management Plan
Although I was not at the clinic the following day for J.J.’s follow up appointment, I was
able to follow up with the Pediatrician and PNP the following week to discuss the child’s
status. It was satisfying to hear that J.J.’s grandmother was able to accompany the child to
the follow up visit. J.J. had remained afebrile throughout the night and had been given
two doses of the Cephalexin. On examination, the PNP noted that the left thigh mass
remained firm, immobile and tender, however the warmth and erythema had decreased.
J.J was able to ambulate and his gait appeared to be unaffected. The grandmother was
Diagnostic Reasoning 11
encouraged to continue with the Elidel cream and the importance of adequate antibiotic
treatment was reinforced. The child was to be seen back at the clinic in two days or
sooner if worrisome symptoms were apparent. At the two day visit as well as the one
week visit, J.J.’s symptoms had improved, the cellulites had significantly resolved and
the atopic dermatitis was controlled with the Elidel cream.
Iatrogenic Outcomes
I.
Noncompliance- Due to the fact that J.J.’s mother is a single parent and that
she depends on her mother to provide childcare while she is at work during
the day, it is difficult for her to provide total care for her son. J.J.’s chronic
atopic dermatitis requires much attention and medication and must not be
ignored. It is for this reason that his cellulitis most likely developed (Burns et,
al, 2004). If J.J.’s mother were to not fill the prescription, not administer the
antibiotics or not return to the clinic as instructed, Child Protective Services
would be notified under the grounds of the Child Protection Law which
defines child abuse and neglect as “harm or threatened harm to a child's health
or welfare by a parent, legal guardian or any other person responsible for the
child's health or welfare” (Children’s Protective Services, 2005).
Plan: In order to ensure compliance, the POH clinic made every necessary
accommodation to guarantee a successful recovery. In addition to education of J.J.’s
mother and grandmother regarding the importance of compliance with therapy and return
visits, J.J.’s family was reminded that if treatment were to fail, hospitalization would be
likely. The PNP and I also spoke with J.J.’s mother regarding accommodations for
Diagnostic Reasoning 12
transportation to and from return office visits if necessary. The clinic also provided J.J.’s
mother with a digital thermometer for home use.
II.
Financial Issues- J.J.’s mother relies heavily on the clinic to receive samples
of J.J.’s Elidel cream. Without insurance and prescription coverage, office
visits and medications can be costly.
Plan: The office visit was waved by the clinic and a special stamp was included on
the prescription which allows the participating pharmacy to supply the patient with
the medication for a $2 fee. J.J.’s mother stated that she could afford the fee and
would fill the prescription upon leaving the office. The PNP also worked to set up a
scheduled mailing of the cream to J.J.’s residence if his mother were unable to
replenish her supply.
III.
Necrotizing fascitis- acute, rapid progression of group A strep through the
skin and subcutaneous layers to the fascial compartments. More common in
immunocompromised children or as a complication of varicella, Necrotizing
fascitis usually begins with cellulites, usually on the leg or abdomen.
Characteristics include severe pain, edema, bullae on an erythematous surface,
and gangrene within a 48 hour period (Burns et. al, 2004, p. 995).
Plan: Prompt surgical debridement, fluid management and prolonged antibiotic
treatment (Burns et. al, 2004, p. 95).
IV.
Toxic Shock Syndrome (TSS)- when caused by streptococcus, “it is usually
associated with bacteremia or focal tissue invasion and 85% is characterized
by sudden, severe localized pain, out of proportion to physical findings”
(Burns, et al. 2004, p. 995)
Diagnostic Reasoning 13
Plan: Hospitalization is required; supportive measures such as fluid management and
antibiotics (Burns et. al. 2004).
Prevention: Thorough cleaning of any breaks in the skin, avoid shared bath or
contaminated water (Burns, et. al, 2004).
Cost Analysis:
As stated above, the office fee of $45 for non insured and Medicaid patients was
waved for the initial and return visits. For an insured patient, the office fee is
normally $65. The cost of Cephalexin oral suspension 250mg/5ml is $25.42/100ml,
and J.J required a total of 160 ml, which would cost approximately $39.00. However
as stated previously, the clinic arranged for a $2 co-pay on the prescription and would
utilize grant funds specifically designated for this purpose to cover the remaining
cost.
The day of the initial visit, J.J.’s mother missed an eight hour shift. At a payed
rate of $6 per hour, the loss for the day was $48.00. Since J.J.’s condition required
frequent watch and reassessment, the family arranged for J.J.’s grandmother to
accompany him to return visits, allowing J.J.’s mother to attend work.
The ICD-9 code appropriate for this diagnosis is 682.6 Cellulitis of leg except
foot (ankle, hip, knee thigh). The visit was approximately 40 minutes in length, and
approximately 30 minutes was utilized for counseling the mother regarding the
condition, plan of treatment, follow up, and insurance issues. Therefore, the visit was
billed as a 99213.
Diagnostic Reasoning 14
Reference
Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2004). Pediatric Primary Care:
A Handbook for Nurse Practitioners 3rd ed. Saunders.
Carpenito, L.J. (1999). Handbook of Nursing Diagnosis, eighth edition. Lippencott,
Philadelphia, PA.
Children’s Protective Services (2005). Child Protection Law. Retrieved from:
http://www.michigan.gov
Jones, D. (2003). The young adult. Common inflammatory skin disorders.
Clinics in Family Practice (5)3, p. 627-652.
Ter Poorten, M.C., & Thiers, B. (2002). Panniculitis. Dermatologic Clinics, (20)3,
421-433.
Ultimate Drug Guide V1.2 Based on Davis’s Drug Guide, 9th Ed. (2004). F.A. Davis Co.,
Philadelphia, Pa.