odjeffery
Case # 3 CC: “Mary is just here for her shots. What should we be…
Case # 3 CC: “Mary is just here for her shots. What should we be giving her for formula?” Mother looks very young, petite, less than 5 ft., about 100 lbs., is Filipino. HPI: Mary is a 20 week old female in your clinic for a 4 month well child check. Mom states, “She was getting constipated, so I switched her to low iron Similac. Is that ok? Also, she is still up twice a night. How much longer will THAT last?” PMH: Normal spontaneous vaginal delivery (NSVD). Apgar scores 9 and 10. Milestones all WNL on previous visit. Has started to try to turn over. Received all required immunizations at 2 month visit. Mary’s physical growth: Plot her growth and fill in her percentiles. Parameter Age Measurement Percentile Length 2 wks. 20″ 2 mos. 21 ¾” 4 mos. 23 ½” Weight Birth 6 lb., 15 oz. 2 wks. 6 lb. 14 oz. 2 mos. 8 lb. 8 oz. 4 mos. 11 lb. 1 oz. Head circ. 2 wks. 34 cm 2 mos. 37 cm 4 mos. 39 cm Allergies: None Current medications: None Family Hex: MGM: 44 yrs. A&W MGF: 46 yrs. A&W PGM: 53 yrs. HTN, NIDDM PGF:
Review of Systems: (obtained from mom)
General: “alert & happy baby”
Skin: “has red marks on back of neck, and blackish marks over butt. Always has a red diaper rash.”
HEENT: No history of head injury; denies any colds since birth. Dried, yellow discharge from both eyes in am, and seems to be getting worse.
Chest/Resp: Noisy breathing sometimes, & breathes fast then slow
Chest/Card: No blueness, able to finish bottle without falling asleep
GI: Usually two soft yel-brown BM’s per day until 2 wks ago, then had 2 days without BM. Now strains with BM at times.
GU: Wets 6-7 diapers/day with clear to lt yellow urine
MSK/Extremities: Moves arms & legs actively
Neuro: Alert, no seizures, not as “jumpy”
Hematological: No excessive bruising, no history of transfusions
Nutrition: Was nursing until about 2 to 3 weeks ago; started on Similac but became very constipated so mother added 1 tsp. of Karo syrup and switched to Low-iron Similac; taking 24 to 32 oz of formula per day; has not yet had cereal or other solid food.
Physical Exam:
Vital Signs: T 98.2 F, P: 106/min; R: 21/min
General: Well nourished, well developed, in no acute distress
Skin: Light brown, dry, smooth, soft, good turgor on abdomen, clean intertriginous neckfolds. Five nonpalpable, erythematous, confluent, irregular 2-3 mm patches on back of neck. Nonpalpable, smooth, bluish-black bruises over lower back, sacrum and buttocks. Tuft of hair at base of sacrum, with no sinus tract visualized. Frontal diaper area, perineal area and around anus bright beefy red with intertriginous folds spared. No red satellite lesions outside diaper area.
HEENT: Normocephalic without masses or lesions, fontanelles palpable, soft, flat; AF: 3×4 cms; PERRLA, EOM’s intact, nares patent, throat without redness or lesions, TM’s grey, sharp LR, mobile
Neck: Supple, full ROM, no adenopathy or thyromegaly
Thorax: Clear to auscultation and percussion
Heart: Regular rate and rhythm, no murmurs
GI: Abdomen soft, round, nontender. Nonpalpable liver & spleen, BS heard
MSK: Femoral pulses 2+ & equal bilaterally, full ROM of hips; neg Ortolani’s sign, no cyanosis, clubbing or edema
Neuro: Babinski + & equivocal, Moro less pronounced
Case Analysis:
Initial thoughts/ideas about differential diagnoses? (Just jot down your first thoughts here)
What is your interpretation of growth patterns that are revealed in the data?
Why might you re-check growth percentiles by plotting the measurements again?
Revised conclusions re: growth patterns:
Differential diagnosis list:
First, list the differential diagnoses for each problem area you have identified.
Then, explain what you will do to rule in or rule out each differential diagnosis.
Compile your final diagnoses into a problem list and number each problem, with WCC as #1. WCC is always #1 & includes immunizations. Then list the other problems in order of priority.
Outline a plan for each diagnosis using this format:
Dx: Diagnostic testing? Why?
Rx: Pharmacologic agents (any Rx, and/ or OTC meds, doses, precautions?)
TLC: Therapeutic Lifestyle Changes (any non-pharmacologic, complementary, or nursing interventions?
PEd: Parent education (any teaching on hygiene, nutrition, development, etc, watchful waiting, anticipatory guidance, red flags?)
F/U: Follow-up (when, how long, how many times?)
Ref: Any referral plans? (when, how long?)
