Case Study Informant Question & Answer Guide (With Explanation)
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Original Question
Case Study Informant: Mother & Father Patient: 4-week-old Timothy Interval History: 4-week-old male infant presents with parents c/o red eyes yesterday that were caked dry this morning, states he has a little nose congestion – asking for meds to help with congestion HPI Infant was well 3 days ago, yesterday baby awoke with some reddening of his eyes were noted. No fever, or cough were present, baby was noted to have eye caked shut this morning upon awakening -crusting was easily removed with warm water; began with some sneezing yesterday, seems to have some nasal congestion, also parents stating he looks a little yellow lately and they are worried about it; no sick contacts Past Medical History: Prenatal/Birth history: 3.5 kg term product of an uncomplicated pregnancy. Labor and delivery + prenatal care from 4 weeks gestation Maternal cx’s for GC and chlamydia were negative No maternal history of STD’s AgNO3 prophylaxis was given in DR Nursery course uneventful Baby and mother d/c’d to home on day #3 of life Neonatal history: At 2-week visit, was doing well, no complications Immunizations: Hep B Nutrition: Exclusively Breast fed- q 2 to 3 hours on demand No supplementation Elimination: Voids 10-12 times/day Stools: soft, yellow seedy stool 1-2 times a day Sleep 1-2 hours at a time during day, @ night may go as long as 4 hours Behavioral Good suck, has some alert times during day Social History: Resides with mother, MGM and 2 maternal aunts, ages 18, 19 in two family house, with adequate heat and hot water, infant sleeps in a bassinet in room with mom, mother is 16 years old and has no plans to return to school because no one can baby sit for him, father of baby lives nearby with his family and is involved in the care Baby receives Medicaid Family History: Mom 16 yr.-healthy Father 23 yr. healthy MGM: 39 years- diabetes MGMF 40 yr.- healthy Father’s family history not known Maternal Aunts: 18 and 19 yr. – healthy ROS: General: Active baby, sleeps about 16 hours a day, awakes to feed q 2-3 hours, no fever or irritability Skin: “looks a little yellow sometimes” over the past week HEENT: Head: no hair loss, + scaly rash to scalp for past week or so Eyes: Bilateral eye redness started 2 days ago, with some crusting this morning No discharge seen, Nose: sneezing a lot and seems to have a runny nose as per parents Ear, turns head to noise and seems to startle with loud noises Mouth drinking well as per mother CV/Lungs: No complaints of cough, color changes, or tachypnea, + sneezes sometimes GI: Feeds well, no vomiting, diarrhea, burps easily, stools 2 times a day, yellow, seedy GU wets about 10 times a day, he was not circumcised and mom states having trouble cleaning under his foreskin, also states his right scrotum ‘looks swollen’ Neuro-Muscular: sleeps “alot” during the day as per mom, moves all extremities Physical Exam: VS T98.9, HR 136 RR: 40 Ht: 52 cm HC38 cm Wt. 4.3 kg General: Alert infant lying quietly in mom’s arms Skin: skin pink and moist with + mild icterus to trunk and abdomen HEENT: Head: + cephalohematoma 2 cm x 1.5 cm to left scalp, AFOF, + scaly red and yellow rash to scalp with some patches on forehead and in eyebrows Eyes: eyelids without swelling, mild erythema of conjunctiva,, sclera with mild icterus,. no discharge present, + red reflex; no nystagmus Ears: symmetrical, no pits or tags, TM’s not able to be visualized Nose; bilateral nares patent with small amount clear d/c Mouth: MMM, good suck, palate intact Neck: no masses, supple Lungs: RR 40 no retractions, lungs CTA bilaterally CV: HRR 136, no murmurs, rubs or gallops, no cyanosis, pulses 2+ to all extremities, capillary refill < 2 seconds, GI: Abdomen soft with + BS, no masses palpated GU: Uncircumcised male, testes: left not palpable, right testes palpable, + right scrotum swollen & transilluminates Rectal: No fissures, + anal wink MS: MAE, + ortalni, + Barlow, no polydactyly or syndactyly Spine: symmetrical, no lateral curve; no dimpling; no sinuses or hair tufts Neuro: Alert infant, + moro, + startle, + sucking Answer the following What are your main concerns related to the primary care of this child? (be comprehensive; may use bullet points, *do not put references.) 2. What is your assessment? List all differential diagnoses with positives and negatives and most likely final diagnosis (20%) Differential Diagnoses Positives Negatives Work up Treatment 3. List your final diagnoses with ICD Codes (maybe multiple) 4. Develop a comprehensive plan of care for 5. Well Child visit Immunizations for current visit Screening for current visit Anticipatory guidance (education for next few months until next visit) Immunizations Screening Nutrition Sleep Elimination Safety/injury 6. Develop a comprehensive plan of care for any diagnoses beyond Well Child Visit include Lab/tests (if needed) Medications with calculated dosages and prescriptions (if needed) Patient Education Referrals Follow up
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