NR 602 Week 3 Sick Child Clinical Case Presentation Complete Solution
Date and Time of History & Physical:
J.B., 5-week-old, Male... [Show More] , Caucasian
Chief Complaint: Frequent vomiting after feedings
J.B. is a 5-week-old Caucasian male who is brought into the office today by his mother with complaints of frequent vomiting after feedings x 4 days. The mother reports that the infant feeds well but then shortly after feeding he vomits and then wants to eat again. Daycare has been saying he has been doing it more the past 2 days. She is concerned that he may not be tolerating his milk-based formula and questions whether he needs to be changed to a soy formula.
Allergies: No known drug, food, or environmental allergies
Current Medications: None
Hep B 1st : 1/29/2020
Hep B 2nd : 2/25/2020
PMHx: No past medical history
Prenatal: Planned pregnancy with prenatal care beginning at 8 weeks gestation. No drug use, alcohol, or smoking during pregnancy. Mother diagnosed with preeclampsia at 35 weeks gestation, managed with labetalol 100mg QD.
Perinatal: Scheduled induction at 39 weeks gestation with Pitocin at St. Francis Eastside Hospital. Duration of labor 16 hours of labor complicated fetal intolerance of labor. Cesarean section performed; mother received Ancef 2 gm IVPB pre-incision and Azithromycin 500 mgs IVPB post-operatively. APGAR’s 9/9. Birthweight: 7 lbs. 8 oz (3538.02 g), Length: 20 inches (50.8 cm), Head circumference: 13.5 inches (34.29cm). Weight at discharge: 7 lbs. 5oz (3401.94 g).
PSHx: Circumcision, no complications
Soc Hx: Lives with mother, father, and sister age 3 years. Attends daycare 3 to 5 days a week based on parents work schedule. The family has no pets.
Enviro Hx: Lives in a single-family dwelling, of new construction. No known toxic exposure to lead, chemicals, or heavy metals. Air purifier in home due to father’s allergies. No secondhand smoke in the home, however maternal grandfather does smoke “but not around the baby”
Diet: Infant consumes Similac Sensitive Non-GMO formula and it is prepared with purified bottled water. Typically consuming 4 to 6 ounces of formula with every feeding every three hours, maybe four hours at night.
Fam Hx: Father: age 28, chronic environmental allergies; Mother: age 25, (G2P2)Preeclampsia and eczema; Sister: age 3, recurrent otitis media & BM-T; Paternal Grandfather: age 53, T2DM and HTN; Paternal Grandmother: age 53, good health; Maternal grandfather: age 56, COPD and hyperlipidemia; Maternal grandmother: age 51,Celiac disease and Ulcerative colitis.
CONSTITUTIONAL: Mother reports infant has been having episodes of frequent vomiting after feedings. “Once he throws up, he acts like he is ready to eat again.” He doesn’t act like he feels bad. Daycare says he has been doing it more the past 2 days but that he is not fussy.
SKIN: Mother denies any rashes or changes in skin color. However, does report minor “cradle cap.”
HEENT: Mother denies noticing any nasal or eye drainage or congestion.
RESPIRATORY: Mother denies any respiratory symptoms.
CARDIOVASCULAR: Mother denies any cardiac symptoms
GASTROINTESTINAL: He has been throwing up after almost every feeding for 4 days. It seems to be happening more often now and he always acts like he wants to be fed again right after he vomits. He will even cry like he is starving. His poops have been normal; he hasn’t had any diarrhea. He doesn’t act like he is gassy or anything.
GENTITOURINARY: Mother reports that the infant is still wetting about 4 to 7 diapers a day. “I already changed 2 this morning.
NEUROLOGICAL: Mother denies
MUSCULOSKELETAL: Mother denies
HEMATOLOGIC/LYMPHATIC: Mother denies
Physical Examination: [Show Less]