Pediatric Nursing - Pain in the neck
This is a Pediatric Management Problem (PMP) designed to test your problem-solving and decision-making abilities.
Instructions: Read the PMP below. Then outline how you would assess and manage the problem. Finally, compare your rationale and decision to that listed in the shaded area,
Please submit material to: Jean Ivey, DSN, CRNP; Pediatric Nursing Journal; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2345 (fax)
Jacob is a 10-year-old boy who presented to an ambulatory clinic with a chief complaint of neck swelling.
History of Present Illness
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Jacob had been evaluated in a local emergency room three times for swelling to the right side of the jaw. His mother stated he had a lesion near the right jaw line that looked like a “pimple” that became infected and then the swelling began. He was initially started on Keflex (Cephalexin) 250 mg three times daily for cellulitis. His condition did not improve and he was started on Augmentin (Amoxicillin/Clavulanate) 875 mg twice daily for 10 days. The anterior cervical region continued to stay enlarged and he developed adenopathy on the left anterior cervical side as well as an enlargement in the left supraclavicular area. Jacob then developed a low grade fever and the Augmentin (Amoxicillin/Clavulanate) prescription was extended to 14 days and his parents were instructed to follow up with his primary care provider. His CBC, rapid strep, and monospot were all normal, but he continued to have a low grade fever and pain when moving his neck. Jacob did not complain of sore throat, ear pain, vomiting, diarrhea, change in appetite, or malaise.
Past Medical History
His past medical history includes asthma and ADD. Immunizations are up to date.
Hobbies
Jacob has many kittens at home that he enjoys playing with. His kittens often paw at his face leading to scratches while Jacob plays with them, but he has not had any previous infections from scratches.
Current Medications
His medications included Augmentin (Amoxicillin/Clavulanate) 875 mg twice daily and Concerta 36 mg daily.
Physical Examination
Physical examination revealed a relatively healthy 10-year-old boy. Oral temperature was 98.6 F, respiration 20 breaths/minute, blood pressure 98/60, and a pulse of 88 beats/minute. The right side of the neck revealed a 10 cm x 5 cm area of cervical adenopathy that was tender to palpation, mobile, and without overlying inflammatory changes or increased local temperature. On the left side of the neck was a 7 cm x 7cm elongated adenopathy that was tender to palpation, mobile, and had increased local temperature. Additionally there was a healing 0.75 x 1 cm maculopapular lesion on the right jaw line. The remainder of the physical examination was normal.
Differentials
Cervical lymphadenitis. In children, cervical lymphadenitis due to Mycobacterium can be common but rarely is there dissemination of the disease.
Lipomas. Cystic lesions or lipomas may also be considered but are often freely movable and come on gradually, whereas lymphadenitis appears more suddenly.
Strep. Group A strep is a common childhood disease that can present with tonsillar exudates, tender anterior lymphadenopathy, and fever. The diagnosis of Group A strep can be determined with a rapid strep test or throat culture.
Mononucleosis. Mononucleosis is a viral infection caused from the Epstein Barr Virus. Children can present with sore throats, fatigue, and lymphadenopathy. Epstein Barr titers can help differentiate past exposure or current infection with mononucleosis.
Cellulitis. Cellulitis is a bacterial infection that extends into the tissues below the outer layer of skin. If often develops where there has been an opening in the skin from a cut, bite, or burn. Cellulitis can cause tenderness, pain, redness, and edema at the site and within the surrounding area.
Discussion
History and laboratory evaluation revealed that he had Cat Scratch Disease (CSD), a self-limited infectious disease most often characterized by regional lymphadenopathy. Cat scratch fever commonly affects immunocompetent humans younger than age 21. The annual incidence overall is 3.7 per 100,000 cases per year with the highest rates in children under the age of 10 (9.3 per 100,000 per year) (Spach, Myers, & Kaplan, 2006). Normally, CSD does not lead to serious illness. There is an estimated incidence of 22,000 cases per year, with 2,000 of those requiring hospitalization due to complications. CSD occurs worldwide with seasonal increases in fall and early winter (Anderson & Edwards, 1995; Spach & Myers, 2005; Busen & Scarborough, 1997).
The most common etiologic agent is the Bartonella Henselae organism. This organism normally is transmitted from a cat through a scratch or break in the skin. Young cats or cats with fleas pose a greater threat. The animal does not act or appear ill, which makes it difficult for patients to identify CSD as a consequence of the cat or kitten (Conrad, 2001; Kravetz & Federman, 2002; Batts & Demers, 2004; Liedholm, 2002). In Jacob’s case, a CBC (complete blood count), metabolic panel, Bartonella Henselae Titers, and Epstein Barr Titers were drawn. The Bartonella Henselae IGG Titer was 1:1024, supportive of the diagnosis of Cat Scratch Disease (CSD). The remainder of the laboratory data was normal.
