Informant: Mother- Tammy Smith 18 year old Haitian female Patient:… Informant:         

Informant: Mother- Tammy Smith 18 year old Haitian female Patient:… Informant:           Mother- Tammy Smith  18 year old Haitian femalePatient:                                    2 week old Alyssa, presents for Well Child Care Interval History:                                    Mom states: ” She cries all the time & she’s constipated” HPI:         Mom states child over the past few days or so has begun to become “cranky” after feeding and unable to be calmed down at times.  Prior to this infant cried only when “she needed changing or had to burp”; mom states baby pulls legs to stomach and cries after each feeding, her bowel movements have gone from once a day at one week of age to every other day now,  as of today she has gone 4 days without a bowel movement,   “She sweats and turns red when she’s pooping”.  Mother states child always seems like she has gas;  “I feel like I’m going crazy because she cries so much, my 3 year old never did this as a baby.  I think there’s something wrong with her stomach.  I think she’s allergic to the milk.”   They did a PPD on me last week and called me to say I needed to speak to you about it.  Past Medical History   Prenatal History/Birth history: Mom P3G1112;  history of PPD 12 mm which was found last week; + history of BCG as a childNSVD 41 week gestation product of an uncomplicated pregnancy, + prenatal care started at 6 weeks gestation;  Labor: 18 hours, 4 hours of pushing, forceps delivery; Apgars: 8 & 9                  Birth weight:  3.6 kg                  Length:  50 cm                  Head Circumference:  34.2 cm                   Nursery course was uneventful, baby and mother d/c’d on day #3 of life                  Discharge weight:  3.4 kg                   Nutrition:              Breast feeding q 2hours- 20-30 minutes at a time during day; supplements with Similac with Fe at night- 4 ounces q 4-6 hours but things it makes her constipated so is requesting to change to Soy or Low iron formula  Elimination:         voids 8-10 times per day                                    BM: “hard formed stool” every 2 to 3 days recently Sleep                       3 hours at a time, awakens once or twice a night for feeding or to be held Behavior/Developmental:, regards mom’s face,  seems  to follow things as per mom                                    Recently has begun to cry a lot during the evening hours  Social  History: Resides with mother MGM, 2 maternal aunts: 20 and 17 and  3 year old brother in 2-bed room apt. with adequate heat and hot water.  Apt building was built in 1929, is a part of low income housing, live in 5th floor walk-up, + occasional rodents seen, landlord minimally helpful with apt clean up and fixtures.  Infant sleeps in crib in room with 3 yo brother and mother.  Mother is presents working on her GED and grandmother and aunts baby-sit for infant.  Father is minimally involved- sees baby once a week, does not contribute to financial needs.  Baby has no medical insurance (Mom is an illegal alien) Immunizations:                  None to date Family History: 3 Year old Brother:           Healthy; was 30 week premieMother                                                       18 years + history of ?  Asthma as a childFather                                       19 years “Healthy”  (Has 3 other children by 2 different  women)MGM:                                        35 years, HTN, ObesityMGF:                                          Died of unknown cause at age 28 yearsMaternal Aunts:                                  ages 20 – Asthma                                                                        17 -healthyFather’s family history: Unknown Newborn Screening:                  TSH  43 mU/L, T4 9.8 ng/dl  ROS: General:                 sleeps 3-4 hours at a time, is cranky after feeds usually cries for up to 45 minutes at a time; likes a pacifier, denies any fever Skin:                         “I think she has pimples on her face”, mom requesting medication for this  HEENT:                   Denies any lethargy or irritability, + hair falling out recently – seen on bed in am                                    + regards mom, appears to look at toys in crib,                                     turns head to noise, + startles to loud noisedrhinorrhea; good suck, + coos Neck                         denies any swelling CV/Lungs               – cough, – tachypnea with feeds, – sweating with feeds,                                    GI:                              feeds well breast fed, difficult to burp recently, cries after feeding for 45 minutes at a time; denies significant vomiting; Hard formed stool q 2-3 days, occasionally spits up after feeding, mom states umbilical cord is falling off and she wants it taken off today because ‘it is gross’ GU                             Wets diaper 8-10 times a day MS:                           moves all extremities, reaches for mom’s face at times Neuro:                    Regards mom, looks at toys                                    Holds head up to about a minute when held on shoulderPhysical Exam; VS:           Temp 100.0 Rectally                  HR           166                  RR:          30                  HC:          36 cm                  Wt:          3.58 kg                  Length: 51 cm General:                 Alert infant, regards mom’s face, sitting quietly in mom’s armsHEENT: Head: Normocephalic, AFOF 2.5 cm x 2.3 cm,                                      + good head control, lifts head when placed on abdomenEyes + red reflex, – discharge, follows past mid-line, + occasional beats of nystagmus noted                                     Ears: symmetrical, canals patent, no pits or ear tagsNose + patent nares, no d/c, no rhinorrhea                                    Mouth + moist mucous membranes, good suck, palate intact, + gag reflexChest:                      Lungs clear to auscultation bilaterallyCV                              HRR 166, S1, s2 no murmurs, rubs or gallops + peripheral pulses 2+ to all extremities,                                     Abdomen:            + soft reducible umbilical mass, umbilical ring 2 cm, umbilical cord dry and partially attached, – soft with + Hyperactive bowel sounds, No massesGU:                            Labia Major with mild swelling, labia minora visible, urethra midline, + mucoid vaginal dischargeMS:                           – Ortalani/Barlow, moves all extremities freelyNeuro:                    alter, active, + startle, + moro, good suck, + palmar reflex, + stepping                                    + red reflex, follows past midline, regards mom, coos, and smiles   What is your assessment? List all differentials and  most likely dx   What is your plan of care for:Working up the differentials & treatment for each differential Well child careImmunizationsScreeningNutritionSleepEliminationAnticipatory guidanceSocial Determinants of healthReferralsFollow up  Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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