Case Study

Case Study
S.P. is a 3-year-old female toddler who presents to the pediatrician’s office for a yearly well visit. The child complains that her leg hurts.

Subjective Data

PMH of otitis media
Immunizations: Up to date
No medications
No allergies
Pain: 3/5 on pain scale
Attends preschool
Unable to recall injuring leg

Objective Data

Vital signs: T 37 P 92 R 18 BP 100/70
Lungs: clear in all fields
Heart rate and rhythm regular
Moving all extremities
+ Range of motion legs and arms
Strength 5/5 in all extremities

1.What other questions should the nurse ask?
2.What techniques are helpful to incorporate in assessing a patient in this age group?
3.What other assessments should the nurse make for this clinical presentation?
4.What are a few of the major differences in the musculoskeletal assessment of a child?
5.What should be included in the plan of care?
6.Based on the readings, what is the most likely cause of leg pain for this patient?

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