Meningococcal Disease

Case Study # 1
University of Oklahoma

September 5, 2014

Case Study # 1
What are Jonathan’s abilities related to data gathering and history? Can he interact with adults?
According to the subjective data, Jonathan interacted appropriately with the healthcare provider.   He provided accurate information regarding the onset and acuity of his pain.   He described how the pain interfered with his level of functioning i.e. pain with eating.
Rationale:   According to Ball et al., children as young as 7 years old can be reliable reporters (Ball, Dains, Flynn, Solomon, & Stewart, 2011, Chapter 1).   Health care providers that incorporate children during their assessment teaches them to understand and care about their health and establishes the importance of building healthy habits for life (Duderstadt, 2014, p. 4).
What is your assessment today and why?
The assessment today will be problem focused.   Focus will be on HEENT due to the patient’s chief concern and physical findings.   Additionally will incorporate, anticipatory guidance as recommended by bright futures.
Rationale:   “The physical exam may be a ritual, but it is an important diagnostic tool when applied by skilled hands and can yield important diagnostic information and decrease the cost of health care (Duderstadt, 2014, p. 5).
Can this patient be safely treated as outpatient or does he need to be admitted?
The patient can be safely treated on an outpatient basis.
Rationale:   According to epocrates, the goals of treatment are to control pain, cure infection and prevent recurrence.   This disorder is usually resolved within 7-10 days with treatment ("Diseases," 2013).
What information (signs/symptoms, laboratory values) indicates the severity of this patient’s illness?
The severity was based on subjective data of pain with eating and patient rating pain 3/10 on the numerical scale.   Objective data was pain to right tragus/pinna, right ear canal erythematous with white exudate.