Case study:

Adam Barnes is a 5 y.o. male, kindergarten child who is brought by mom with the complaint of “my bottom itches”. The itching has been worsening over the last 2-4 weeks. The child is now complaining it is worse at night and awakens him repeatedly. The child is not fully toilet trained and has stooling accidents and wears pull ups. He does have a history of constipation. On physical exam his findings include: mild anal excoriations with minimal erythema and uneven finger nails from his nail-biting habit. Additional risk factors include: recent change in bobble bath and laundry detergent.

 

Instructions: Answer the following questions. As you can see, I already have the primary, differential diagnosis, and laboratory/diagnostic test.

 

Management Plan Template: 

(Every section of your management plan must have intext citations to support your plan).

 

Primary Diagnosis and and Differential Diagnosis ICD-10 code: Also include any procedural codes.

3-5 Differential Diagnoses- Why? What made you select each one as a DDX? How did you rule out? This would be a good area to include references.

 

Primary Diagnosis:

    Pinworms B80

Differential Diagnosis:

    1. Encopresis F98.1  

    2. Tinea Cruris B35.6   

    3. Dermatitis L30.9

 

Additional laboratory and diagnostic tests: May be necessary to establish or evaluate a condition. Some tests, such as MRI, may require prior authorization from the patient’s insurance carrier.

      

– Diagnostic tests: Anal tape test (87172)

 

Consults: referrals to specialists, therapists (physical, occupational), counselors, or other professionals. If you are sending to hospital, what orders would you write for a direct admit?

 

Therapeutic modalities: pharmacological and nonpharmacological management. Give specific medications, dosing and duration. Include anticipated therapeutic modalities/symptomatic treatment for patients if they are sent to ED or directly admitted.

 

Health Promotion: Address risk factors as appropriate. Consider age-appropriate preventive health screening.

 

Patient education: Explanations and advice given to patient and family members.

 

Disposition/follow-up instructions: when the patient is to return sooner, and when to go to another facility such as the emergency department, urgent care center, specialist, or therapist.

 

 Scholarly references (minimum of 3, timely, that prove this plan follows current standard of care).

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