PBL Case Discussion: Initial Visit- Meet the Family Part One (graded) 


Background and Visit One

Background: 

Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Jo-age 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather: Tom-age 62. 

Setting: Rural U.S.

Office: Rural, NP owned, Family Practice Clinic

PART 1: Today is a busy day in your rural family practice clinic. You are reviewing the chart of your next appointments and realize that there is very little information and that you are scheduled to do a well-woman and two well-child exams for the same family. Your office schedules 20 minutes each for well exams. Upon entering the room, you note a Latino-looking woman who appears in her 40s who sits focused on paperwork, a male infant on her lap crying and grabbing for her pen, while a preschool-aged appearing female is sitting at your computer pretending to type on the keyboard.  

As you introduce yourself, the mother tells the infant to “Stop!” smacking his hand and causing him to cry. She states, “I am so sorry. They usually behave. I am Kayla Field, and this is Riley and Jo.” You then inquire as to the reason for their visit. The mother reports they recently moved to the area to live with her parents due to a recent separation from her husband, and she is there to have a physical exams before they lose her husband’s health insurance benefits. She reports that the children are currently healthy and had a pediatrician at their previous home, but she would like to establish care with your clinic moving forward.   She also has a teenage daughter that refused to come today because she wanted to ‘hang out with friends’.

The mother reports she would really like to get her well exam done today as she will lose her insurance soon as well with the impending divorce. 

KAYLA

HPI: Kayla reports that she is healthy and takes no medication. She has no symptoms that she can think of other than she is currently having trouble falling and staying asleep, but associates this with stress and with sleeping in the same room with her two younger children. She is a 15 year smoker of 1PPD up until 18 months ago when she quit with the pregnancy of Riley. She is concerned about finances today and reports ongoing fatigue. She has not and menses since the birth of her last child. She is not currently sexually active with either men or women and has been abstinent for the last 6 months. 

PMH: Kayla denies any surgeries or past medical history other than four pregnancies, three births, one pre-term, and two C-sections with the last two births. She had one miscarriage at 10 weeks when she was 16. She also reports that she had PCOS as a teenager and has always had irregular menses. She had gestational diabetes with the last birth and preeclampsia causing the early delivery of Riley. She has no allergies. She is currently taking Advil PM every night to sleep and drinking a glass of wine. She does not routinely exercise. She often skips breakfast and lunch and eats whatever the children eat for dinner, which is often processed, or quick food.

CHILDREN 

HPI: The mother denies any recent illnesses in either child and reports they are here for their check-up. She does report that since moving in with her parents, it has been difficult to get the children to go to bed at night and stay in bed and expresses extreme frustration with this. Jo is waking frequently to ‘play’ and Riley is started waking up crying again at least two times per night which wakes up Jo.  This has been going on for at least the last month. She reports that the children are eating three meals per day and two snacks, one at bedtime and one in the afternoon between lunch and dinner. They do brush their teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home. 

PMH: Jo: Full-term gestation, born cesarean section, weight. 7lb 4 oz. There were no complications in pregnancy, but the mother did smoke 1 pack-per-day throughout pregnancy. There were no hospitalizations—NKDA. The daily medication was chewable children’s multivitamin with iron. They eat three meals and two snacks. There is a great deal of juice (at least 2-4 glasses per day), soda, and processed or quick foods given in the house.

Riley: Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother, but this is not treated with anything.  “His nose constantly runs”.  He has had a couple of issues of otitis media since birth with fever but no other major illness.  

Immunizations: 

Jo – Birth – Hep B, 2 months –  DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, HIB COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV. Hep B, 12 months – MMR, Varicella, Hep A, PCV 13, 18 months – DtaP, Hep A

Riley - Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months - DTaP, HIB (COMVAX), PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B

Social History: Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 4 hours away. Jo will be starting kindergarten this fall in the community’s elementary school. 

Family History: They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  Kayla’s mother has a history of hyperlipidemia, Type 2 DM, glaucoma, breast cancer at age 50 treated with lumpectomy, and Hypertension. She is Latin American in descent, emigrating from Cuba in the 1970s. Kayla’s father has a history of hypertension, hyperlipidemia, and an MI with stenting 5 years ago.  The mother has two siblings; a younger brother in the U.S. Navy, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

Discussion Questions Part One:

Please prepare yourself to complete the well-woman exam and one of the well-child exams of your choosing. 

Per patient- give additional HPI information and questions you would like as well as PMH, Family History, and ROS.  Begin to lay out the objective portion of your note for each patient.

What is your differential diagnosis list for this visit thus far with rational for each of your two patients? 

For the child you choose, please list all of the appropriate anticipatory guidance that should be done at a well visit for that age. Expand on one of the topics from your list and provide the education you would offer with citations.