You are working as the assessment nurse in a clinic that is located within a community hospital. The hospital is in a rural area and the closest tertiary care facility is 40 miles from the clinic. The clinic serves as the primary care provider for the close-knit community.
The first client that you see is Casey. Casey is a 3- year- old female. Her mom brought her to the clinic because of a fever of 103.5 for 2 days that has accompanied cough, coryza (runny nose), and conjunctivitis. As you are completing your health history you learn that Casey’s dad has returned from Iraq about a month ago and she has a little sister at home who is 11 months old. The cultural assessment indicates that the family is Jewish American. The parents both hold master’s degrees – dad has a career in the military and mom is staying home at this time to raise the family. She does free-lance journalism for several blogging sites.
During your systems evaluation, you note the following: Koplik’s spots are located inside both cheeks and the beginning of a maculopapular rash that is on the forehead and down both cheeks. The mother has expressed a great deal of concern because since the fever has started Casey has been lethargic and not wanting to eat.
You have a strong suspicion that Casey has measles. You tell the parent to remain in the clinic room with the children while you go get the primary care physician. The physician completes a physical assessment and confirms the diagnosis of measles.
No real patient is described, the writer just needs to write as if it really a patient.