IPE-Interprofessional Cross-Campus Collaborative Case

Cody James Urgent Care Visit

Setting: Outpatient Urgent Care Clinic
Name: Cody James   Age: 11-year-old   Gender: M   Ethnicity: Caucasian
Reason for Visit: Acute right wrist pain following a soccer injury

Date of visit:
Vital Signs:
BP 106/70 mmHg; Respirations 18/min; Pulse 110 /min, Temperature 37.3°C (99.1°F), Height 4’8”; Weight 40 kg (88 lbs); BMI 19.7

HPI

Patient is an 11-year-old boy who presents to the urgent care with his parents due to acute right wrist pain following a fall during a soccer game about 1 hour ago. He collided with an opponent and landed on his outstretched right hand. He immediately experienced sharp pain in his wrist and digits and could not move his hand or wrist without severe pain. His parents noted swelling around his wrist and immediately brought him in for urgent evaluation.

His mother provides some general history about Cody and expressed concerns about his overall well-being. She reports that while Cody is still excited to play soccer, she has noticed that his skin color is pale, he appears more fatigued, and he is more short of breath with the same level of exertion that he has always been putting in. He is also getting sick frequently. She states that he “catches every cold or bug that goes around the classroom.” In addition to frequent respiratory infections, she also reports that he is having nosebleeds that are occurring both during his soccer games as well as in the middle of the night. Lastly, she noticed increasing bruising recently on his body but had attributed them to soccer and “rough housing” with friends. He lives at home with his parents and is only involved in soccer as his extracurricular activity outside of school.

History

Past Medical History

• ADHD
• Speech Language Impairment

Past Surgical History

• None

Family History

• Mother, 45 y/o - Hearing loss (uses assistive device)
• Father, 41 y/o -
• Sister, 14 y/o- Bulimia nervosa (recovered)

Social History

• No alcohol consumption
• No smoking
• No illicit drug use
• Lives at home with parents and sister

Medications and dosages the patient is currently taking:
None

Allergies - No Known Drug Allergies

Review of Systems
General: Positive for fatigue, pale appearance, and bruising easily. Denies recent infections other than common colds.
HEENT: Positive for frequent nosebleeds. No headaches or visual changes.
Respiratory: Positive for shortness of breath on exertion. No cough or wheezing.
Cardiovascular: No chest pain or palpitations.
Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain.
Musculoskeletal: Positive for right wrist pain and swelling. No other joint pain or swelling.
Neurological: No seizures or changes in mental status.
Psychiatric: No anxiety or depression reported.

Physical Examination
General: Well-nourished, well-developed young male in mild distress due to pain. He appears pale and fatigued, sitting on the exam table.
HEENT: Normocephalic, atraumatic. Conjunctivae are pale, and sclerae are non-icteric. No signs of nasal trauma. Nasal mucosa without erythema or edema, no active bleeding from the bilateral nares. No foreign bodies or obvious sources of bleeding were visualized. The septum is midline without deviation or perforation. Turbinates are mildly enlarged bilaterally without signs of active bleeding, purulence, or crusting. Posterior pharynx without blood or erythema, no tonsillar hypertrophy, Oral mucosa moist.
Thyroid: No thyromegaly. No thyroid nodules are appreciated. No cervical lymphadenopathy.
Lungs:Clear to auscultation bilaterally in A/P lung fields.
CV: Regular rate and rhythm with no murmurs, rubs, gallops.
Abdomen: Soft, non-distended protuberant abdomen. No tenderness to palpation x 4 quadrants. Abdomen without varicosities, rashes, masses, hernias, or ascitic fluid. Normoactive bowel sounds x 4. There is no guarding or rigidity. No rebound tenderness to palpation. No CVA tenderness to palpation bilaterally.
Right hand:The skin of the right hand and all digits are intact, with no open wounds or sores. Nails are intact without cyanosis, cap refill < 2 seconds bilaterally upper and lower extremities. Ecchymosis and edema are noted around the right proximal 3rd phalanx. Severe bony tenderness to palpation over the 3rd proximal phalanx. Limited active and passive range of motion of the 3rd proximal phalanx secondary to pain. Unable to fully flex or extend the 3rd proximal phalanx. All other digits have intact skin, without tenderness to palpation, and there is full active and passive range of motion of the digits.
Right Wrist: The skin of the right wrist is intact, with no open wounds or sores. No deformity is appreciated. There is no tenderness to palpation over the ulnar or styloid processes. There is no anatomical snuff box tenderness.
Left hand: The skin of the left hand and all digits are intact, with no open wounds or sores. Nails are intact without cyanosis, cap refill < 2 seconds—non-tender to palpation, full active and passive range of motion of the digits in all planes.
Left Wrist: The skin of the left wrist is intact, with no open wounds or sores. No deformity is appreciated. There is no tenderness to palpation over the ulnar or styloid processes. There is no anatomical snuff box tenderness.
Skin: Multiple ecchymoses scattered throughout bilateral lower extremities in various stages of healing. There are no linear loop marks, skin burns, or handprints on the body.
Right Shoulder: There is mild elevation of the lateral clavicle without skin tenting compared to the left shoulder. Palpation of the AC joint reveals significant point tenderness at the AC joint. There is no crepitus on palpation. No tenderness to palpation of the biceps tendon, coracoid, or subacromial space. The arm is held flexed at 90 degrees. There is a limited active range of motion with significant pain and limitation with abduction, flexion, and extension. Negative Neer’s test, negative drop arm test. Positive Scarf test and cross-arm test.
Left shoulder: No clavicle deformity is appreciated. There is no tenderness to the AC joint, biceps tendon, coracoid, or subacromial space palpation. There is full active and passive range of motion without pain in forward flexion, abduction, adduction, external rotation, and internal rotation. Negative Neer’s test, negative drop arm test, negative scarf test, negative cross arm test.
Neurovascular: Distal sensation and motor function in the right upper extremity are intact. Pulses at the radial and brachial arteries are palpable and equal bilaterally.

Diagnostics:

LABORATORY RESULTS:

CBC

Right hand and wrist X-ray

Radiologist interpretation: Fracture extends through the growth plate (physis) and into the metaphysis. The epiphysis appears intact with no involvement in the fracture. There is soft tissue swelling present around the site of the fracture, correlate clinically.

Conclusion: Right proximal middle finger Salter-Harris II fracture with mild displacement and no significant angulation.

R shoulder X-ray: AC separation, aka sprain

Radiologist interpretation: No fracture is identified. The right acromioclavicular joint is disrupted, with elevation of the clavicle with respect to the acromion. Coracoclavicular distance is also increased. Features are those of a left grade III acromioclavicular joint injury.

1. Assessment and Plan
   1. Right proximal middle phalanx Salter-Harris II fracture
      1. Aluminum finger splint applied on the right middle phalanx as well as a short arm splint was placed in the office to immobilize the wrist. The patient tolerated the procedure well. Patient and family understand return precautions and should call if experiencing any of the following: Numbness/tingling in fingers, persistent pain, swelling or discoloration of the extremities or fingers. When showering, avoid getting the splint wet, and wrap it in the protective bag. Do not place sharp objects, such as pens or forks, inside the splint if it becomes itchy. This is to avoid causing potential skin injury.
         1. Pain control was discussed, and RX was sent for Ibuprofen 400 mg q4 hours with food as needed for pain control.
         2. Referral to orthopedics will be placed ASAP for further monitoring and possible cast application.
         3. Follow up with orthopedics within one week.
   2. Grade 2 acromioclavicular sprain, Right shoulder
      1. Placed in a sling immobilizer today and will need to follow up with Orthopedics within one week. An orthopedics referral will be placed today. Do not: Ignore any worsening pain, swelling, or redness around the injured joint. Contact your doctor if you experience these symptoms. Advised to:
         1. Rest and avoid strenuous activity that can aggravate the injury. Avoid overhead, pulling, pushing, lifting, and contact sports.
         2. Ice: Apply ice packs wrapped in a towel to the affected area for 15-20 minutes at a time, several times a day. Do not apply ice directly to your skin.
         3. Compression: You might be fitted with a sling to immobilize your shoulder and reduce pain. Wear the sling as directed by your doctor, typically for a few hours at a time or only when needed for pain relief.
         4. Elevation: Elevate your injured shoulder above your heart whenever possible to reduce swelling.
   3. Fatigue
      1. CBC in-house concerning possible blood dyscrasia, especially in the context of other abnormal lab findings that the patient demonstrated on CBC, including leukocytosis, erythrocytopenia, and thrombocytopenia. It was recommended that the mother contact his pediatrician for a stat referral to hematology for further investigation and workup of lab abnormalities and concerning symptomatology.
   4. Leukocytosis: See Above: Requires referral from Pediatrician to see Peds Oncology
   5. Thrombocytopenia: See Above: Requires referral from Pediatrician to see Peds Oncology
   6. Erythrocytopenia, See Above: Requires referral from Pediatrician to see Peds Oncology.
   7. Bruising with minimal to no trauma
      1. Bruising is confined solely to bilateral lower extremities. Discussion with mother on abuse risk factors, which is found to be an unlikely cause due to no previous history of fractures or injuries, patient lives at home with his parents and is not watched by any adults other than his parents. In the office, he shows no signs of fearful behavior. Advised mother to continue monitoring for new bruise development and inquire if any known fall or injury occurred to that area.
   8. Frequent Nosebleeds
      1. Nasal exam without abnormality or foreign body. Consider frequent URIs and/or allergic causes. Avoid picking your nose. You may apply lubricant, such as Aquaphor, to the nasal canal to prevent dryness.
   9. Frequent URIs
      1. Follow up with his pediatrician and ensure compliance with all age-appropriate vaccines. Consider immunology evaluation given frequent illness history and discuss the benefits of frequent hand washing and using a mask when others are sick.

Providers Signature: Penelope Woods PA-C

Cody James Pediatric Visit

Setting: Outpatient Urgent Care Clinic
Name: Cody James   Age: 11-year-old   Gender: M   Ethnicity: Caucasian
Reason for Visit: Acute right wrist pain following a soccer injury

Date of visit:
Vital Signs:
BP 112/72mmHg; Respirations 18/min; Pulse 105 /min, Temperature 36.9°C (98.4°F), Height 4’8”; Weight 40 kg (88 lbs); BMI 19.7

HPI

Cody is an 11-year-old male patient with a diagnosis of Acute Lymphoblastic Leukemia (ALL), who presents today for a one-month follow-up since starting chemotherapy. Cody began chemotherapy about ten days after his ALL diagnosis, under the care of the pediatric oncology team.

Since starting chemotherapy, Cody has been closely monitored by his oncologist. The serial laboratory results his oncologist has been tracking demonstrates a positive response to treatment with expected improvements in clinical markers. However, Cody has been experiencing significant fatigue and muscle weakness. His parents have observed a noticeable decline in energy levels including no longer engaging in physical activities with friends. His parents have opted to homeschool him due to concerns about his increased susceptibility to infections. Both parents have observed that his stutter has become more pronounced since being homeschooled. Cody is consistently repeating initial sounds like "C-c-can I have a p-p-piece of paper?" He will also perform whole word repetition such as "Can-can I go to the b-bathroom?" and syllable repetition as in "I-I-I want to play soccer.”

Recently, Cody sustained a right middle finger fracture and an AC sprain of his right shoulder. He has already been seen, and treated, by orthopedics and his mother states that he is improving.

In addition to the current symptoms, Cody has a history of Attention Deficit Hyperactivity Disorder (ADHD). His ADHD has made it challenging for him to stay focused on his schoolwork, especially since he had difficulty with completing handwritten tasks after his finger injury.

His oncologist recommended Cody be seen today for further evaluation and management of his symptoms. His mother happily reports that Cody has not contracted any recent colds or viruses. He also has not had any recent nosebleeds.

History

Past Medical History

• Acute Lymphocytic Leukemia (ALL)
• ADHD
• Speech Language Impairment
• Right proximal middle phalanx Salter-Harris II fracture
• Grade 2 acromioclavicular sprain, right shoulder
• Fatigue
• Leukocytosis
• Thrombocytopenia
• Erythrocytopenia
• Recurrent nosebleeds
• Frequent upper respiratory infections

Current Medications and Dosages

• None

Past Surgical History

• None

Family History

• Mother, 45 y/o - Hearing loss (uses assistive device)
• Father, 41 y/o -
• Sister, 14 y/o- Bulimia nervosa (recovered)

Social History

• No alcohol consumption
• No smoking
• No illicit drug use
• Lives at home with parents and sister

Allergies - No Known Drug Allergies

Review of Systems
General: Positive for fatigue, pale appearance, and bruising easily. Denies recent infections.
HEENT: Negative for nosebleeds. No headaches or visual changes.
Respiratory: No shortness of breath on exertion. No cough or wheezing.
Cardiovascular: No chest pain or palpitations.
Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain.
Musculoskeletal: Stiffness of right wrist and right shoulder. No other joint pain or swelling.
Neurological: No seizures or changes in mental status.
Psychiatric: No anxiety or depression reported.

Physical Examination
General: Well-nourished, well-developed young male in no distress. He appears pale and fatigued, sitting on the exam table.
HEENT: Normocephalic, atraumatic. Conjunctivae are pale bilaterally, and sclerae are non-icteric. Nasal mucosa without erythema or edema, no active bleeding from the bilateral nares. Posterior pharynx without blood or erythema, no tonsillar hypertrophy, Oral mucosa moist.
Thyroid: No thyromegaly. No thyroid nodules appreciated. No cervical lymphadenopathy.
Lungs:Clear to auscultation bilaterally in A/P lung fields.
CV: Regular rate and rhythm with no murmurs, rubs, gallops.
Abdomen: Soft, non-distended abdomen. No tenderness to palpation x 4 quadrants. No CVA tenderness to palpation bilaterally.
Right hand:Nails are intact without cyanosis, cap refill < 2 seconds bilaterally. No bony tenderness, erythema, or edema of the 3rd middle phalanx. Slight decrease in ROM of the third middle phalanx with extension. Full active and passive ROM of all other digits.
Right Wrist: No deformity is appreciated. There is no tenderness to palpation over the ulnar or styloid processes. Mild limitation in active and passive range of motion of the joint, most noticeable during supination and pronation and at the extremes of flexion and extension. No pain with ulnar or radial deviation. There is no anatomical snuff box tenderness.
Left hand: The skin of the left hand and all digits are intact, with no open wounds or sores. Nails are intact without cyanosis, cap refill < 2 seconds—non-tender to palpation, full active and passive range of motion of the digits in all planes.
Left Wrist: No deformity is appreciated. There is no tenderness to palpation over the ulnar or styloid processes. Full active and passive range of motion of the joint. There is no anatomical snuff box tenderness.
Skin: No ecchymosis appreciated.
Right Shoulder: There is no deformity present compared to the left shoulder. Palpation of the AC joint reveals no tenderness. There is no crepitus on palpation. No tenderness to palpation of the biceps tendon, coracoid, or subacromial space. There is a limited active range of motion with flexion and extension. Negative Neer’s test, negative drop arm test. Negative scarf test and cross-arm test.
Left shoulder: No clavicle deformity is appreciated. There is no tenderness to the AC joint, biceps tendon, coracoid, or subacromial space palpation. There is full active and passive range of motion without pain in forward flexion, abduction, adduction, external rotation, and internal rotation.
Neurovascular: Distal sensation and motor function in the right upper extremity are intact. Pulses at the radial and brachial arteries are palpable and equal bilaterally.

In house diagnostics:

1. Acute Lymphocytic Leukemia (ALL)
   1. Continue follow up with Peds Oncology to monitor response to chemotherapy with routine blood work and management of side effects of chemotherapy.
   2. Request progress notes from Peds Oncology office to update patient’s medications.
2. Fatigue:
   1. Suspect that this is a side effect from chemotherapy. Consider diagnosis to include comorbid depression given recent cancer diagnosis.
   2. Referral to Physical Therapy: For evaluation and management of cancer-related fatigue. Physical therapy can help with energy.
   3. Energy Management: Educate the patient and caregivers on managing energy levels, including rest periods and pacing activities.
   4. Nutritional Support:
      1. Balanced Diet: Ensure the patient consumes a balanced diet rich in fruits, vegetables, lean proteins, and whole grains to maintain energy levels.
      2. Small, Frequent Meals: Encourage small, frequent meals and snacks to avoid energy dips.
      3. Hydration: Maintain adequate hydration, aiming for at least 8 cups of water per day, unless otherwise advised by a healthcare provider.
   5. Sleep Hygiene: Promote good sleep hygiene practices, such as:
      1. Keeping a regular sleep schedule.
      2. Creating a restful sleep environment (cool, dark, and quiet).
      3. Avoiding caffeine and electronic devices before bedtime.
      4. Rest Periods: Encourage short naps or rest periods during the day, but avoid long naps that can interfere with nighttime sleep.
3. Mild Depression:
   1. PHQ9 Modified for Teens- Scored 9, equating to mild depression.
   2. Referral to Behavioral Health for evaluation and talk therapy
   3. Patient appears to be having difficult transition to new life circumstances, including cancer diagnosis, injury to right hand and shoulder, homeschooling, and familial financial struggle.
   4. No Suicidal/homicidal ideation, parents to monitor symptoms
4. ADHD
   1. Potential exacerbation in light of change from in person schooling with IEP to homeschooling after cancer diagnosis.
   2. Referral to Behavioral Health for possible CBT/behavior modification assistance. Possible benefits:
      1. Helps children with ADHD develop problem-solving skills, manage impulsive behaviors, and improve their emotional regulation.
      2. CBT can also address co-occurring issues such as anxiety and depression.
5. Speech Language Impairment: Worsening during homeschooling:
   1. Referral to Speech Language Pathologist for specialized therapy
      1. Education for Family and Friends: Educate family members and friends about stuttering to foster a supportive environment. Encourage patience and active listening without interrupting or finishing sentences.
      2. Adaptive Communication: Use of non-verbal communication methods such as gestures, writing, or using technology to assist communication when necessary.
6. Right wrist pain: Status post fall on outstretched hand. Patient still having stiffness with everyday use, suspect ligamentous sprain after injury.
   1. Referral to Occupational Therapy for gross motor strength evaluation after middle phalanx fracture. Continue to follow up with all planned orthopedic appointments.
7. Grade 2 acromioclavicular sprain, right shoulder:
   1. Cleared by Orthopedics to return to activity as tolerated, in-office patient has continued stiffness in the shoulder.
   2. Physical Therapy: Referral for physical therapy to improve shoulder strength and function, and to develop a rehabilitation plan.
   3. At home activities: Range of Motion Exercises: Gentle passive range of motion exercises to maintain mobility without stressing the AC joint.
      1. Pendulum exercises
      2. Gentle shoulder shrugs and scapular retractions
   4. Activity Modification: Avoid activities that may aggravate the injury until full recovery.
8. Frequent nosebleeds: Mother reports no recent episodes of nosebleeding, continue to monitor.
9. Frequent upper respiratory infections
   1. Frequent handwashing and masking
   2. Up to date with all age appropriate vaccinations: Vaccinations are often scheduled during periods when the child’s immune system is more robust, typically during maintenance phases of chemotherapy or after completion of treatment.
   3. Discuss PPSV23 vaccine with Peds Oncology

Providers Signature: Clay Tourmaline PA-C

Athletic Training Note

James, Cody

R AC, shoulder

R Wrist/hand

S: 11-yr old male, club soccer player; hx of ADHD; speech language impairment; high WBC count; ran into opponent; FOOSH on R hand; presents with following:

• Sharp pain at wrist and fingers
• Removed from play
• Severe pain with flex/exten of wrist and fingers
• Edema noted immediately
• Pain noted in R AC area of shoulder (secondary to wrist)
• Pain with R shoulder flexion noted during wrist x-ray

O: edema noted on the R wrist and fingers; piano key sign noted on AC joint

A: (+) cross over arm test

(+) Obrien’s test

X-ray results (+) piano key sign for Grade II AC sprain

X-ray results (+) R proximal 3rd finger Salter-Harris II fracture (casted)

P: follow up with pediatrician; follow up with OT for wrist/finger cast; follow up and care plan for AC sprain (refer to AT for RTP guidelines); follow up with oncologist

Follow-up notes:

S: 11-yr old patient Cody history of leukemia and doing Chemotherapy for several months; mother suspects signs of bulimia (frequent bathroom visits after eating large meals) in daughter; Daughter (Kelly) seems to retreat when attention given to brother Cody; severe tooth and mouth pain

O: denies bulimia (emotional)

A: mouth pain and tooth pain; mouth ulcer

P: create care plan for Cody

Audiology Chart Notes

PATIENT: Kristi James

DATE OF VISIT: (2 months before Cody’s accident)

Kristi was seen today for a routine 6-month check for her Phonak Audeo receiver-in-the canal hearing aids. She reported that the hearing aids seem to be working well and she has no trouble keeping them clean. She noted that she uses a headset for work and sometimes forgets to put her hearing aids back in when she takes the headset off. She said that she hears well with the headset and reported no concerns hearing at work. She reported that forgetting to put her hearing aids back in after work causes difficulty for her on occasion. One example of this is struggling to hear if the family goes out for the evening and she has left the hearing aids at home. She reported that on occasion she forgets to put her hearing aids in even on days where she does not use the headset.

The hearing aids appear to be well-maintained and in good working order. Datalogging indicates intermittent hearing aid use with average daily use of 2 hours over the past 6 months.

When asked, Kristi said she felt it would be most beneficial to talk about how she forgets to put her hearing aids in. This was the focus of today’s visit. She said that she would like to wear them more often but has struggled developing a habit of putting them in, even though she has been wearing them for 2 years. She noted that she was embarrassed about this and felt she should be better at wearing her hearing aids by now. She also said she was frustrated about having one more thing to keep track of in her sometimes-hectic life. She said that she does hear better with them in and does not have complaints or concerns about physical comfort or benefit of the hearing aids.

I reassured Kristi that it is ok if it takes a long time to develop a habit and feelings of frustration are normal. I invited her to tell me more about how she feels and she spent some time sharing about difficulties balancing work and home life with two school-age children. I asked if she would like help figuring out how to develop the habit of wearing her hearing aids and she said that she would appreciate that. To start, I asked her to tell me about ways she had been successful in developing new habits in the past. After some discussion and considering different strategies, she determined that setting a reminder in her phone would be the best thing to try first. I offered to send her scheduled reminder e-mails and she said she would like to receive weekly reminder e-mails every Monday mid-morning for one month.

Plan: Follow up in 3 months or sooner as needed. Weekly reminder e-mails scheduled in secure messaging system.

DATE OF VISIT: (1 month after Cody’s accident)

Patient postponed follow-up appointment via voicemail message. She noted some family struggles and health concerns regarding her son and requested a 3-month postponement. Note made to contact her in 2 months to schedule a follow-up.

Dental Notes for Cody James

Patient: Cody James, an 11-year-old male, presented to a dental office with a Chief Complaint of susceptible gums, pain upon chewing, and bleeding.

Medical History: Medical History (Based on Summarized Narrative): Two weeks ago, while playing a fast-paced game of soccer, Cody ran headlong into a member of the opposing team, falling on his outstretched right hand. He immediately experienced sharp pain in the digits and wrist and was taken off the field and into the care of his parents. Cody couldn’t move his hand and wrist without severe pain, and as the parents noticed that it was beginning to swell, they decided to take him to the pediatric urgent care center since it was Saturday, and his pediatrician wasn’t available.

Upon arrival at the Urgent Care, Cody was taken to Radiology, and after the x-ray, a CBC was obtained. The x-ray results were reviewed, and a right proximal middle finger Salter-Harris II fracture was identified. Also identified was a Grade 2 acromioclavicular sprain (slight elevation of the lateral clavicle), which was noted through a shoulder x-ray, which was ordered when Cody experienced pain with lifting his arm for the arm/wrist x-ray. The hand and wrist were splinted, and a follow-up appointment was made with Cody’s pediatrician in 3 days. Additionally, Cody was referred to physical therapy or his athletic trainer to manage the shoulder injury. The blood test revealed a higher-than-normal white cell count and reduced levels of platelets and red blood cells.

Cody had an appointment with his pediatrician within the week, who referred him to pediatric oncology. The oncologist ordered a bone marrow biopsy, which confirmed the diagnosis of acute lymphocytic leukemia (ALL). The same week, Cody began chemotherapy at the local cancer center with a pediatric oncologist directing his care, which was expected to continue over the next 2-3 years.

Cody’s emotional state was affected as he worried about the impact of his injury on his soccer engagements. Financial concerns about hospital bills and treatment expenses also weighed on his mind.

Diagnosis:

Based on confirmed acute lymphocytic leukemia, the dental examination and radiographic findings further explored the effects of ALL on the oral cavity and surrounding structures.

Dental Examination and Treatment Recommendations (Incorporating Pediatric Oncology Information):

The patient had a mild fever of 103.1 F with a heart rate of 134 beats per minute. Extraoral examination revealed painless bilateral lymphadenopathy below the mandibular angle. Intraoral examination observed no salivary gland swelling and revealed buccal mucosa pallor with well-demarcated, painless, soft, bilateral maxillary gingival overgrowth. Significant bleeding of the gingival tissues was observed upon palpation. The exam noted mobility of the mandibular primary molars. The dentist requested a panoramic film and bitewings. Upon obtaining consent from Mrs. James, the panoramic and a full series of X-rays were taken. Both radiographic exams showed no specific signs of dental infection contributing to the patient’s condition, and although the mandibular primary molars had minimal mobility, radiographic evaluation of the periodontal ligament space did not show enlargement for these or other teeth. These images are a valuable baseline for assessing oral conditions during cancer therapy. Primary mandibular molars had occlusal caries.

The dentist called the patient’s pediatric oncologist to obtain blood work results and find the status of Cody's treatment. The dentist received Cody’s latest blood test, which revealed:

Severe anemia (low hemoglobin, 11.2 grams/dl; average values 13.2 to 16.6 grams/dl), thrombocytopenia (low platelet count, 45,000 platelets/mcL; average values 150,000-300,00 mcL), and leukopenia (low white blood cell count, 600 per microliter; average value 5,000 to 10,000 per microliter). Initially, the patient went into a rapid phase of induction chemotherapy to achieve remission. The patient received three medications: L-asparaginase, vincristine, and dexamethasone, each given during the first month. It is highly recommended that patients receive a comprehensive oral exam before starting chemotherapy.

1. Dental findings included Mouth ulcers, gingival abnormalities, petechiae, and spontaneous bleeding. Both lower primary molars exhibited small caries lesions that must be addressed ASAP.
2. Oral mucosa is susceptible, with multiple ulcers, omnipresent candida infection signs, and slightly dry mucosa.
3. Management of oral infections and pain: Provide appropriate pain management strategies to alleviate his discomfort and to eliminate mucositis and candida infection.

The following medications may be prescribed for Cody James based on the presented case:

Diphenhydramine 0.075%

Hydrocortisone 0.125%

Nystatin 100,000 U/ml (units/milliliter)

Mix and dispense 30 milliliters (ml) of nystatin suspension at 100,000 U/ml or 3 million units of nystatin powder with 60 milligrams of hydrocortisone and diphenhydramine HCL syrup to bring the total volume to 240 ml.

Antibiotics: In cases of orofacial infections, antibiotics may be prescribed to prevent or manage potential infections. Commonly used antibiotics for dental infections include Amoxicillin or Clindamycin. However, it's essential to consider the patient's allergies and any drug interactions before prescribing antibiotics.

Prescription Pain Medication: In cases of severe pain that cannot be effectively managed with over-the-counter analgesics, a short-term prescription for potent pain medication, such as Hydrocodone or Oxycodone, may be considered. However, these medications should be used judiciously, as they carry a risk of dependence and should only be used when necessary and under close supervision.

Topical Anesthetics: Topical numbing gels, like Benzocaine, can temporarily relieve localized oral pain, mainly if there are oral mucosal injuries or irritation.

Mouthwash or Oral Rinse: An alcohol-free antimicrobial mouthwash or oral rinse may be recommended to help maintain oral hygiene and prevent infection in the affected area.

It is essential to carefully assess the patient's medical history, current medications, and any allergies before prescribing any medications. Additionally, patient education should be emphasized, explaining the proper usage, potential side effects, and adherence to prescribed medication regimens.

Dietary restrictions for Cody James following chemotherapy the following recommendations may be suggested:

Soft Diet: Initially, Cody James should adhere to a soft diet to avoid putting excessive pressure on the injured area. Foods that require minimal chewing, such as soups, mashed potatoes, yogurt, smoothies, and soft fruits, can be included in his diet.

Hard and crunchy foods, like nuts and chips, should be avoided to prevent additional mucosal irritation.

Limit Acidic Foods and Beverages: Acidic foods and drinks, such as citrus fruits and carbonated beverages, can irritate oral tissues and affect healing. It's advisable to limit their consumption.

Hydration: Encourage the patient to maintain proper hydration by drinking plenty of water throughout the day. Staying hydrated is essential for overall health and aids in the healing process. Frequent sips of the water will help with dry mouth.

Follow Dentist's Recommendations: Based on his case and treatment plan, Cody James should follow any specific dietary recommendations provided by the dentist or his medical team.

Follow-up:

The frequency and duration of follow-up visits may vary based on the severity of the injury and the specific treatment interventions. However, a general guideline for follow-up visits may include:

1. Initial Follow-up (within a week): Schedule an initial follow-up appointment within a week of the initial dental visit to excavate all caries lesions, if possible, put permanent composite restorations on caries-affected primary molars, and check for any signs of oral infection or complications. Evaluation of mucosal healing and reduction of candida infection should also be performed.
2. Subsequent Follow-ups (as needed): Depending on the patient's progress and response to treatment, subsequent follow-up visits may be scheduled every few weeks or as determined by the dentist. These visits will allow for ongoing monitoring of oral condition and any signs of infection.
3. Regular Check-ups: Cody James should continue with regular dental check-ups and cleanings, typically scheduled every six months following the initial healing period. These routine appointments will help maintain oral health and detect potential issues early on.

Patient Education: Patient education on proper oral hygiene practices and adherence to dietary restrictions should be reinforced during follow-up appointments. Additionally, encouraging open communication with the patient about any concerns or changes in symptoms will help ensure that Cody James receives comprehensive care and support throughout his recovery.

Prognosis: The prognosis for Cody James’ dental condition will depend on his compliance with the prescribed treatment plan, emotional well-being, and his overall response to cancer treatment.

Pt is a right hand dominant 11 y/o male who sustained a right middle finger proximal phalanx Salter-Harris II fracture post fall on outstretched hand while playing soccer.

Pt was referred to OT for evaluation and treatment 1-2x/week for 6 weeks. Pt is 6 weeks post fracture with no limitations for therapy on ROM/strength as fracture is well healed.

S: Pt and parent report that pt has difficulty with writing, tying shoes, and brushing teeth due to decreased right middle finger ROM. Pt and parent report difficulty with gripping and pulling handles (car door, refrigerator) and opening drink bottles/snack packages due to decreased ROM and strength.

O: Pt accompanied by parent during OT evaluation in outpatient clinic x 60 minutes.

ROM:

Pt’s shoulder is being evaluated by physical therapy. Pt presents with decreased Right shoulder AROM.

Strength:

Fine Motor Coordination:

9 hole peg test

Gross Motor Coordination:

Box and Blocks assessment

Sensation:

Pt denies numbness and tingling in bilateral hands. Light touch screening of bilateral upper extremities normal.

Edema (circumferential measurement):

ADLs:

IADLs:

A: Pt presents with decreased right middle finger ROM, grip and pinch strength, and coordination which is decreasing his ability to perform writing, dressing, grooming, bathing, and self-feeding independently. Pt would benefit from continued skilled occupational therapy to increase his right middle finger ROM, grip/pinch strength, and coordination in order to increase his independence with ADLs/IADLs.

P: Continue OT 1-2x/week x 6 weeks for ROM, strengthening, ADL/IADL training/simulation, and modalities.

PT Notes

Name: Cody James
Age: 11 years old
Occupation: 6th grader, Bush Elementary
Sex: male
Referring healthcare professional: Penelope Woods, PA-C
Date of Referral:
Date of PT evaluation:

S:

C/C: “I get tired easily, but I want to go back to playing soccer again.”

History:
Cody James is an 11-year old boy who was referred to physical therapy (PT) following diagnosis of acute lymphocytic leukemia. Chemotherapy treatment has been started and from the referral received, patient has been responding favorably with treatment. He is followed closely by his oncology team. Prior to cancer diagnosis, Cody fell and fractured his right proximal middle finger (Salter-Harris II fracture) with a grade 2 right acromioclavicular sprain. His right hand/wrist was immediately put into a splint. He is scheduled for an x-ray on the fractured site in 3 weeks. Cody has been diagnosed with ADHD and has an Individualized Education Plan (IEP) for speech language impairment (SLI) for stuttering. The patient has been playing soccer since first grade and his parents have been very supportive of his interest in the sport.

Patient already expressed extreme fatigue at the start of the evaluation and told PT that “I would like to go home now…..I don’t want to do anything.” Patient also reported discomfort in right shoulder area.

Social history:

• Lives with parents: Dad (Blake) is a maintenance technician at a local hospital while Mom (Kristi) is a virtual assistant
• Has a teenage sister (Kelly) who suffers from bulimia and has been seeking medical attention
• Mom has bilateral hearing impairment and uses bilateral hearing aids
• Dad has good health insurance coverage, although money has been tight lately

O:
V/S: BP – 110/80 mmHg
    HR – 65 bpm
    RR – 16 cpm
    PR – 70 bpm

Ocular inspection:

• Patient appeared very fatigued while seated, had to rest head on Mom’s shoulder
• Finger splint in place (right wrist/hand); no visible discoloration of right finger nail beds

Manual Muscle Testing –right hand/wrist muscles not tested as patient strongly refused to participate in testing

Myotome Testing – not tested at this time, patient refused

Sensory Testing – was only able to test bilateral C2 to C5, grossly graded 2/2 (light touch and pin prick for pain). All other dermatomes not tested this time due to patient refusal

Range of motion: Except for right hand/wrist (not tested as still in splint), all other joints grossly graded full ROM; patient refused to participate in actual ROM measurement for all other joints

Muscle palpation – not tested due to patient refusal, but previous medical report noted tenderness over right acromioclavicular area

A:
PT Impression: generalized deconditioning secondary to chemotherapy treatment

Problem lists:

1. Generalized fatigue secondary to chemotherapy treatment
2. Anticipated* decreased ROM of right hand and wrist
3. Anticipated* decreased ROM right shoulder secondary to acromioclavicular sprain
4. Anticipated* decreased strength of right hand, wrist, and right shoulder muscles
5. Anticipated* decrease in participation with PT sessions due to fatigue

*anticipated as baseline not established at this time due to patient’s refusal to participate in full evaluation of affected areas

P:
Short term:

1. Gradually increase patient’s endurance level in between chemotherapy sessions to prevent further deconditioning – incorporate play activities and consider joint sessions with occupational therapist and/or speech-language pathologist
2. Patient and family education re: monitoring of circulation on right hand (i.e. nail bed coloration) and prevention of further sprain right acromioclavicular joint
3. Patient and family education regarding energy conservation techniques

Medium term:

1. Address anticipated decreased range of motion in right hand and wrist
2. Address anticipated decreased strength in right hand and wrist muscles
3. Address anticipated decreased strength of right shoulder muscles
4. Continue working on building patient’s endurance level
5. Continue monitoring patient’s mental health (e.g. signs of depression) and refer to appropriate professional for further evaluation and management (e.g. psychologist)

Signed: John Doe, PT

       Date

‘Pediatric Cancer Patient Educators’ Certified Health Education Specialists (CHES) in the Health Care setting may perform the following duties: Deliver and assess health education programs, coordination and outreach, enrollment and initial health assessments, motivate others to initiate behavior change, communicate/liaise with primary care physicians, hospitals and other health care providers, plan for health education interventions, translation of medical and health education material for dissemination to client/patient.

Public Health Resources for the family – to start with:

Health dept: https://www.maricopa.gov/5302/Public-Health

Federally Qualified Health Centers: https://carelistings.com/federally-qualified-health-centers/mesa-az

Community Mental Health Center: https://www.maricopa.gov/5043/Mental-Health-Substance-Use

Maricopa County: Maricopa Healthy App: https://health.maricopa.gov/app/

PATIENT/FAMILY EDUCATION FOR Acute lymphocytic leukemia

Give Education/Recommendation - Use Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5235950/

https://www.lls.org/sites/default/files/National/USA/Pdf/Publications/PS33_ALL_2018_final.pdf

https://www.cancer.gov/types/leukemia/patient/child-all-treatment-pdq

https://kidshealth.org/en/parents/all.html

https://leukemiarf.org/patients/

https://leukemiarf.org/patients/resources/children/

PATIENT/FAMILY EDUCATION FOR Financial Health/Health Insurance/Healthcare Resources

Give Education/Recommendation - Use Resources

Adelante Healthcare - Mesa: https://adelantehealthcare.com/locations/mesa/

Financial Literacy/Assistance - A New Leaf:
https://www.turnanewleaf.org/services/financial-empowerment/
https://www.turnanewleaf.org/services/financial-empowerment/financial-wellness/

MesaCAN: https://www.turnanewleaf.org/services/financial-empowerment/mesacan/

Hearing aid resources:

Adherence to using hearing aids:

https://ncbi.nlm.nih.gov/pmc/articles/PMC10138368/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630952/
https://www.tandfonline.com/doi/full/10.3109/14992027.2016.1144240

Support for adherence: Brief Motivational Interviewing:
https://motivationalinterviewing.org/understanding-motivational-interviewing
https://knowledgeplus.nejm.org/wp-content/uploads/2023/10/motivational-interviewing.pdf

Assistance: https://www.mesaaz.gov/residents/limited-income-assistance-programs

PATIENT/FAMILY EDUCATION FOR homeschool groups

Give Education/Recommendation - Use Resources

https://afhe.org/

https://afhe.org/maricopa

https://www.thehomeschoolmom.com/homeschooling-in-arizona/homeschool-organizations-support-groups/

http://www.knowledgehouse.info/azhsgroups_maricopa.html

https://www.homeschoolinginarizona.com/

PATIENT/FAMILY EDUCATION FOR Mental Health

Give Education/Recommendation – Use Resources

Information for patient educators – bulimia - https://bulimiaguide.org/information_for_educators_coaches/

NEDA Toolkits – patient education - https://www.nationaleatingdisorders.org/toolkits/

Education – bulimia - https://www.mayoclinic.org/diseases-conditions/bulimia/diagnosis-treatment/drc-20353621

NIH – bulimia - https://www.nimh.nih.gov/health/topics/eating-disorders

NLM – bulimia - https://www.ncbi.nlm.nih.gov/books/NBK562178/

NEDA – bulimia - https://www.nationaleatingdisorders.org/bulimia-nervosa/

Treatment education - https://www.eatingdisorderhope.com/information

Sliding fee schedule clinics: https://www.azdhs.gov/prevention/health-systems-development/sliding-fee-schedule/index.php

Free MH services:

https://www.freementalhealthservices.org/ci/az-mesa
https://www.freeclinics.com/cit/az-mesa

Specialize – eating disorders:

https://www.psychologytoday.com/us/treatment-rehab/az/mesa?category=eating-disorders
https://www.nationaleatingdisorders.org/free-low-cost-support/

ADHD – CDC - https://www.cdc.gov/adhd/hcp/treatment-recommendations/index.html

ADHD support: https://www.psychologytoday.com/us/groups/az/maricopa-county?category=adhd

ADHD – patient education/treatment - https://www.uptodate.com/contents/treatment-of-attention-deficit-hyperactivity-disorder-in-children-beyond-the-basics

ADHD patient education/symptoms - https://www.uptodate.com/contents/1210#

Free materials - https://www.cdc.gov/adhd/communication-resources/index.html

Support for adherence: Brief Motivational Interviewing:

https://motivationalinterviewing.org/understanding-motivational-interviewing
https://knowledgeplus.nejm.org/wp-content/uploads/2023/10/motivational-interviewing.pdf

PATIENT/FAMILY EDUCATION FOR Light physical Activity

Give Education/Recommendation - Use Resource

Local YMCA has recreational and youth development programs on sliding fee scale: https://www.ymca.org/locations/east-valley-family-ymca

Speech-Language Pathology Report

Client Name: Cody James
DOB:
Age: 11 years
Date of Report:

Background Information

Cody James is an 11-year-old male diagnosed with ADHD and Speech Language Impairment (SLI) related to stuttering. He attends Bush Elementary and is currently in the 6th grade, with an Individualized Education Plan (IEP) for his speech and language needs. Cody has been an active soccer player since first grade and participates in club soccer. Recently, Cody was diagnosed with acute lymphocytic leukemia and has been undergoing chemotherapy. Additionally, Cody's mother has a hearing impairment and wears hearing aids.

Assessment Information

Presenting Concern

Cody's fluency has been observed to decline, with increased stuttering occurrences, particularly since beginning chemotherapy. Stress from his medical condition, treatment, and subsequent lifestyle changes are likely contributing factors. Cody's speech disfluencies are characterized by:

• Sound repetitions (e.g., "C-c-can I have a p-p-piece of paper?")
• Whole word repetitions (e.g., "Can-can I go to the b-bathroom?")
• Syllable repetitions (e.g., "I-I-I want to play soccer")

Fluency and Stress

Fluency disorders such as stuttering can be exacerbated by stress. Cody's recent medical diagnosis and treatment regimen, combined with the physical and emotional stress of managing leukemia and its symptoms, have likely increased his anxiety levels. The familial stress, including his mother's hearing impairment and his sister's bulimia recurrence, further contribute to the overall stress within the home environment. These stressors may negatively impact Cody's speech fluency.

Relationship to Other Diagnoses

1. Hearing Loss in the Family: Cody's mother's hearing impairment could indirectly affect Cody's stress levels. Communication difficulties and the added strain of managing Cody's health might contribute to an environment of heightened stress and anxiety for Cody.
2. Speech Language Impairment (SLI): Cody’s pre-existing SLI makes him more susceptible to speech disfluencies under stress. His recent medical challenges, including chemotherapy-induced fatigue and muscle weakness, have compounded his difficulty in maintaining fluent speech.

Diagnosis

Based on the observed speech patterns and the impact of current stressors, Cody is diagnosed with mild to moderate stuttering. His stuttering is characterized by increased frequency and severity of sound, word, and syllable repetitions.

Recommendations

1. Further Assessment: A comprehensive evaluation by a pediatric psychologist is recommended to assess the impact of stress and anxiety on Cody’s overall well-being and fluency. Additionally, re-evaluation by an audiologist is suggested to ensure optimal hearing support for his mother, reducing familial communication stress.
2. Speech Therapy: Continued speech therapy focusing on fluency shaping and stress management techniques is essential. Therapy should aim to reduce stuttering severity and equip Cody with strategies to manage speech disfluencies in stressful situations.
3. Counseling: Family counseling is recommended to address the emotional and psychological impact of Cody's diagnosis and treatment on the family dynamics. Support for Cody's sister, Kelly, should be included to manage her bulimia and to address feelings of neglect or stress.
4. School Support: Given Cody’s homeschooling situation due to his medical condition, it is important to ensure that his educational needs, including accommodations for his ADHD and stuttering, are met. Coordination with his IEP team to update and implement necessary supports is crucial.
5. Medical Coordination: Regular communication with Cody’s medical team, including his oncologist and pediatrician, is essential to monitor his overall health and its impact on his speech and language development.

Conclusion

Cody James presents with mild to moderate stuttering, likely exacerbated by the significant stress associated with his recent leukemia diagnosis and treatment. A multidisciplinary approach, including speech therapy, psychological support, and family counseling, is recommended to address his fluency issues and support his overall well-being.

Prepared by:
John Smith, M.S., CCC-SLP
Speech-Language Pathologist

Athletic Trainers use a medical based model to provide comprehensive patient care in the domains of prevention; clinical evaluation and diagnosis; immediate and emergency care; treatment and rehabilitation; and organization and professional health and well-being. Athletic Trainers are highly qualified, multi-skilled health care professionals who collaborate with physicians to provide total patient care. Athletic Trainers work under the direction of a physician as prescribed by state licensure statutes.

"An audiologist is a person who, by virtue of academic degree, clinical training, and license to practice is uniquely qualified to provide a comprehensive array of professional services related to the identification, diagnosis and treatment of persons with auditory and balance disorders, and the prevention of these impairments. Audiologists serve in a number of roles including primary service provider, clinician, therapist, teacher, consultant, researcher and administrator. In addition, the supervising audiologist maintains legal and ethical responsibility for all assigned audiology activities provided by audiology assistants and audiology students."

Source: Academy of Doctors of Audiology

What is professional counseling?
“Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health.”

Learn more at: https://www.counseling.org/mental-health-counseling/what-is-counseling

What is a Dentist?
You will find an interesting article here about the important interconnection between oral health and systemic health. So don't forget the importance of collaborating with the dentist!

“Doctors of Osteopathic Medicine use a unique whole-person approach to help prevent illness and injury.

Accounting for approximately 11% of all physicians in the United States, Doctors of Osteopathic Medicine, or DOs, bring a unique, patient-centered approach to every specialty across the full spectrum of medicine. They are trained to listen and partner with their patients to help them get healthy and stay well.”

Learn more at: https://osteopathic.org/what-is-osteopathic-medicine/what-is-a-do/

Registered Nurses

“Registered nurses (RN) form the backbone of health care provision in the United States. RNs provide critical health care to the public wherever it is needed.
Key Responsibilities

• Perform physical exams and health histories before making critical decisions
• Provide health promotion, counseling and education
• Administer medications and other personalized interventions
• Coordinate care, in collaboration with a wide array of health care professionals”

Occupational therapy is the only profession that helps people across the lifespan to do the things they want and need to do through the therapeutic use of daily activities (occupations). Occupational therapy practitioners enable people of all ages to live life to its fullest by helping them promote health, and prevent—or live better with—injury, illness, or disability.

Common occupational therapy interventions include helping children with disabilities to participate fully in school and social situations, helping people recovering from injury to regain skills, and providing supports for older adults experiencing physical and cognitive changes.

Occupational therapy practitioners have a holistic perspective, in which the focus is on adapting the environment and/or task to fit the person, and the person is an integral part of the therapy team. It is an evidence-based practice deeply rooted in science.

See also: https://www.aota.org/career/become-an-ot-ota/about-the-profession

Learn more at: AOTA.org

Physical therapists are movement experts who optimize quality of life through prescribed exercise, hands-on care, and patient education. After making a diagnosis, physical therapists create personalized treatment plans that help their patients improve mobility, manage pain and other chronic conditions, recover from injury, and prevent future injury and chronic disease.

Physical therapists empower people to be active participants in their own treatment, and they work collaboratively with other health professionals to ensure patients receive comprehensive care. Physical Therapy entry-level educational programs are at the doctoral level with subsequent educational opportunities for fellowship and residency. Physical therapists work in a wide range of specialty areas for which they can obtain specialty certification e.g. acute care, aquatics, cardiovascular & pulmonary, geriatrics, home health, neurology, oncology, orthopedics, pediatrics, sports, and women's health.

See Also: https://www.apta.org/your-career/careers-in-physical-therapy/becoming-a-pt

Learn more at: apta.org

What is a PA?

“PAs (physician associates/physician assistants) are licensed clinicians who practice medicine in every specialty and setting. Trusted, rigorously educated and trained healthcare professionals, PAs are dedicated to expanding access to care and transforming health and wellness through patient-centered, team-based medical practice.”

Learn more at: https://www.aapa.org/about/what-is-a-pa/

https://assets.speakcdn.com/assets/2251/hespa_competencies_and_sub-competencies_052020.pdf

• Area I: Assessment of Needs and Capacity
• Area II: Planning
• Area III: Implementation
• Area IV: Evaluation and Research
• Area V: Advocacy
• Area VI: Communication
• Area VII: Leadership and Management
• Area VIII: Ethics and Professionalism

Individuals who hold the CHES® and MCHES® certifications have the versatility and skillsets to practice in many different career settings, across the country and even overseas. Job settings were identified in the Health Education Specialist Practice Analysis (HESPA) include the following: Community/non-profit, Healthcare/Hospitals, Government, School Health, Academia/Universities, and Business/Worksite. Job titles in the hospital and healthcare sector can vary. Some common titles include Community Benefits Manager, Outreach Manager, Patient Educator or Program Manager, Wellness Coordinator, and RN/Health Educator. Health Education Specialists in the Health Care setting may perform the following duties:

• Deliver and assess health education programs
• Coordination and outreach
• Enrollment and initial health assessments
• Motivate others to initiate behavior change
• Communicate/liaise with primary care physicians, hospitals and other health care providers
• Plan for health education interventions
• Translate of medical and health education material for dissemination to client/patient

The profession of social work aims to improve functioning and overall well-being within individuals, families, organizations, and communities through change efforts. With a focus on the poor, the oppressed, and the vulnerable, social sciences such as sociology, psychology, political science, public health, economics, law, community and organizational change, are applied. Needs assessments are completed and interventions are planned to solve personal and social problems within client systems to enhance social change. Social work practice is often divided into three levels. Micro-work involves working directly with individuals and families, such as providing individual counseling/therapy or assisting a family in accessing services. Mezzo-work involves working with groups and communities, such as conducting group therapy or providing services for community agencies. Macro-work involves fostering change on a larger scale through advocacy, social policy, research development, nonprofit and public service administration, or working with government agencies. Professional training requires a master’s degree and most states require professional licensure. Social Workers are employed in a variety of settings including healthcare, government agencies education, corrections, public health, and public policy.

Source: Wikipedia

Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults.
Learn more at: https://www.asha.org/Students/Speech-Language-Pathology/