Discussion Peer/Participation Prompt Due Sunday by 11:59 pm
Instructions:
Please respond to two peers’ posts regarding their differential diagnosis list and/or plan.
What did you find interesting about their response?
How did their differential diagnosis list or plan compare to yours?
Do you agree with their plan and recommendations?
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
please use updated references
i will provide each peer post for response please make sure separate responses
peer#1
Whitney Bowles
SundayMay 29 at 4:16pm
Positive Information
Nightmare’s starting a few months ago. Child does not remember episodes.
Started kindergarten and a soccer league.
The child’s father vapes in the home.
Dental caries B, C, M, L. Mild erythema and swelling gingivae.
The child’s parents report being social drinkers with occasional alcohol on the weekends.
The child’s BMI: 22.54 (97%).
Negative Information
The child reports liking school and has friends.
The child states that her favorite part of the school day is “PE”.
The child’s father reports no concerns with development or behavior.
The child’s mother reports that there were no complications during pregnancy or at birth.
The child lives with both parents who have been married for 2 years.
There are no firearms in the house.
The child is well developed, well-nourished and hydrated with no apparent distress. Exam is normal except mouth.
Would there be any other information you would want to obtain?
Are there siblings and if so, did they have issues with nightmares?
Has there been recent illness?
What does intake look like in the hours prior to bedtime?
Is there access to medications in the home?
How long do the episodes last?
Is there anything that makes the episode better or worse?
Diagnoses
Night terrors- Priority Diagnosis
Nightmares
Somnambulism
Plan of Care for Night Terrors
Night terrors are a common sleep disturbance in children. The most common time on onset is between the ages of 3 and 7. Night terrors are described as a sudden awakening of the child with terror like behavior (Leung et al., 2020). Episodes generally last 45-90 minutes each and the child usually does not remember the episode. This can be extremely disturbing for parents to witness so it may be a common presentation to the Pediatrics office.
Diagnostic: The diagnosis of night terrors is based on subjective data provided by caregivers. Careful assessment by the practitioner can assure a proper diagnosis. Ruling out potential neurological disorders is also a priority so an in-depth neurological examination should be performed.
Therapeutic: The goal is to reduce the incidence of night terrors. Factors that can contribute to night terrors include extreme tiredness, overstimulation, lack of sleep schedule, illness and ingestion of sugar or caffeine prior to bedtime. The parents should be educated on avoidance of trigger substances as well as moving bedtime earlier to increase the length of sleep the child is exposed to (Van Horn & Street, 2021). We also want to assure the child is safe during the night terrors and isn’t exposed to areas when she may be injured. Most likely, the increase in activities coupled with the decreased sleeping time is cause for the night terrors. The expectation is that the child will outgrow the night terrors by age 10.
Collaboration: There is no need to refer the child to another provider or outside resource at this time.
Expected Health Promotion
Health promotion would include avoidance of sugary foods and drinks in the evening as well as avoidance of caffeine. Sleep schedule should be consistent, and bedtime should be moved up earlier. A five-year-old child should be getting 10 to 13 hours of sleep every night so this child is lacking appropriate sleep time (Paruthi et al., 2016).
Expected Developmental Milestones
Developmental milestones differ for each age group. The developmental milestones expected for a five-year-old include:
The child should be able to follow simple rules and take turns during a game.
The child should be able to speak clearly and have a short conversation.
The child should be able hop on one foot.
The child should be able to count to 10.
The child should be easily understood by others.
The child should be able to write some letters of the alphabet.
References
Leung, A., Leung, A., Wong, A., & Hon, K. L. (2020). Sleep Terrors: An Updated Review. Current pediatric reviews, 16(3), 176–182. https://doi.org/10.2174/1573396315666191014152136 (Links to an external site.)
Paruthi, S., Brooks, L. J., D’Ambrosio, C., Hall, W. A., Kotagal, S., Lloyd, R. M., Malow, B. A., Maski, K., Nichols, C., Quan, S. F., Rosen, C. L., Troester, M.
M., & Wise, M. S. (2016). Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 12(11), 1549–1561. https://doi.org/10.5664/jcsm.6288 (Links to an external site.)
Van Horn, N. L., & Street, M. (2021). Night Terrors. In StatPearls. StatPearls Publishing.
peer#2
Sarah Johnson
MondayMay 30 at 9:47am
Our case study this week is that of M.M. who presents to the clinic with nightmares.
Pertinent Positives
Pertinent positives include nightmares that started 3 months ago but are increasing in frequency, now twice weekly. She wakes up from nightmares approximately 2 hours after going to sleep. When she wakes up she is screaming, confused, and clammy and parents are unable to get her to calm down during the epidsode. The patient does not remember the episodes. Recent life changes include starting full day kindergarten and soccer. Both parents work full time. Father vapes in the home, both parents are social drinkers on the weekend. She is positive for dental caries on B, C, M, L and has mild erythema and swelling of gingivae. She is positive for high BMI of 97%, however both her height and length are in the 98%ile and 93%ile respectively. She was born via c-section for breech position.
Pertinent Negatives
Pertinent negatives include a recent well child visit that showed no developmental concerns. There have been no changes in her home situation. Socially M.M. is enjoying school and has made new friends. She is negative for significant family medical history. Immunizations are up to date. She is negative for headaches, trauma, falls, skin rashes or lesions, concerns with ENT, pain with neck ROM, masses and lumps. She is negative for chest pain, cyanosis, heart racing, and sweating, negative for abnormal heart sounds. She is negative for respiratory symptoms such as cough, congestion, wheezing, or difficulty breathing, negative for rhonchi, rales, wheezes. She is negative for GI symptoms such as food intolerance, weight loss, N/V, constipation or diarrhea, negative for abnormal bowel sounds, masses, tenderness and organomegaly. She is negative for musculoskeletal concerns, negative for abnormal muscle tone, strength, or range of motion. She is negative for neurological symptoms such as change in senses. She is negative for psych concerns such as difficulty concentrating, tearful episodes, anxiety, or seclusion. She is negative for increased thirst or urination. She is negative for bruising or bleeding. She is well nourished and not in distress and is dressed appropriately.
Other Information Needed
I would want to know if the child is using electronics before bed, limiting screen time to 1 hour per day, a 24 hour routine, bed time routine, symptoms during the day such as need for nap during the day, hyperactivity, and how the child is functioning (Garzon PhD CPNP-PC PMHS FAANP FAAN, Dawn Lee et al., 2019). It would also be important to assess the family for any sleep disorders as they can be familial (Garzon PhD CPNP-PC PMHS FAANP FAAN, Dawn Lee et al., 2019). Other things that may be helpful include whether the child grinds her teeth, snores, sleep walks or talks or wets the bed (Meltzer et al., 2014; Morse & Kotagal, 2021).
Differential Diagnosis
Sleep Terrors (F51.4)
Nocturnal Seizures (G40.309)
Obstructive Sleep Apnea (G47.33)
Plan for Priority Diagnosis
A sleep study with EEG would be advised for this patient to help determine the type of sleep disorder (Morse & Kotagal, 2021). The increase in frequency may show inadequate sleep (Morse & Kotagal, 2021). Sleep terrors most commonly occur between the ages of 4-12 years of age. They usually gradually resolve on their own, however safety and supportive care are needed during the night terror (Morse & Kotagal, 2021). Some behavioral strategies such as planned awakening of the child may be a helpful first step. The parents awaken the child 15-20 minutes prior to the typical time of the night terror and comforting the child then putting them back to bed may help resolve the night terrors (Meltzer et al., 2014; Morse & Kotagal, 2021). Other options include medications such as low dose clonazepam can be helpful if all other causes of sleep disturbance have been ruled out (Morse & Kotagal, 2021).
If the sleep study shows nocturnal seizures, a referral to neurology is indicated to discuss potential medications.
If this child’s history is positive for snoring, it is possible she has obstructive sleep apnea. If mild, the provider may consider a trial with nasal corticosteroids, however if this is not successful the child would need referred to pediatric ENT.
References
Garzon PhD CPNP-PC PMHS FAANP FAAN, Dawn Lee, Starr MS APRN BC (PNP) CPNP-PC, Nancy Barber, Brady PhD RN CPNP-PC, Margaret A., Gaylord PhD RN CPNP-PC PMHS FAANP FAAN, Nan M., Martha, D. P.-B., & Karen, D. C. (2019). Burns’ pediatric primary care (7th ed.). Elsevier.
Meltzer, L. J., Plaufcan, M. R., Thomas, J. H., & Mindell, J. A. (2014). Sleep problems and sleep disorders in pediatric primary care: Treatment recommendations, persistence, and health care utilization. Journal of Clinical Sleep Medicine, 10(04), 421–426. https://doi.org/10.5664/jcsm.3620 (Links to an external site.)
Morse, A. M., & Kotagal, S. (2021). Parasomnias of childhood, including sleepwalking (R. D. Chervin & L. Wilkie, Eds.). UpToDate. Retrieved May 30, 2022, from https://www.uptodate.com/contents/parasomnias-of-childhood-including-sleepwalking?search=night%20terrors%26source=search_result&selectedTitle=1~29&usage_type=default&display_rank=1
