Diagnosis and treatment plan

Need to know what the diagnosis (could be multiple) and treatment plan? Any information that can help me make sure I am on the right path

Case Study

Amber jackson

age 20 weeks

Opening Scenario

Amber Jackson is a 20-week-old female in your office for a four-month WCC.  Both parents are present.

History of Present Illness

(Obtained from mother)

“Amber is here for her well-child check and her immunizations. She is a great baby and doesn’t cry much.  We do have some concerns about constipation.  What should we be giving her for formula?  Starting 2 weeks ago she was getting constipated, so we switched her to low-iron formula.  We have been giving her 1oz of prune juice mixed with 1oz of water when she seems constipated.  It seems to work, and we have given this 3 times over the last 2 weeks.  Is that okay?  Also, she is still up twice a night.  How much longer is this going to last?”

Medical History

Normal spontaneous vaginal delivery at term.  Developmental milestones all within normal limits on previous visit.  Immunization record show in Table 1.  Growth is shown in Table 2.

Family Medical History

MGM: 44 years old (A&W)

MGF: 46 years old (A&W)

PGM: 53 years old (HTN, DM)

PGF: 44 years old (prostate cancer)

Mother: 27 years old (A&W)

Father: 37 years old (A&W)

Immunization Record of Amber Jackson

Growth of Amber Jackson

Social History

Lives with both parents in an apartment. Father works as a truck driver and frequently travels.  Mother stays with child at home.  No siblings. Mother is from the Philippines and of small stature (4 ft 11 in, 105 lb).  Mother has been in this country for about 5 years.  No local family, some local friends.

Medications

None

Allergies

1. NKDA

Review of Systems

1. General:  Good energy level, no fevers, in good general health
2. Integumentary:  No itching, lesions, or rashes
3. HEENT:  Mild transient congestion after feeding; no difficulty swallowing; no concerns about hearing or vision; not pulling at ears
4. Respiratory:  Denies apnea, shortness of breath, and cough
5. Cardiovascular:  No cyanosis or diaphoresis
6. Gastrointestinal:  No vomiting or diarrhea; usually 2 soft, brown BMs per day until 2 weeks ago, then had 2 days without BMs after which formula was changed; returned to daily BM – strains with BMs at times
7. Genitourinary: No odor to urine; 6-7 wet diapers per day
8. Musculoskeletal:  Moves all extremities routinely
9. Neurological:  No seizures, alert, smiles spontaneously

Physical Examination

Vital Signs:  Temperature 98.0˚F; pulse 106 bpm; respirations 24/min

General:  Well developed, well nourished; in no acute distress; smiling during examination

HEENT:  Normocephalic without masses or lesions; posterior fontanel closed, anterior fontanel palpable, soft, and flat; pupils equal, round, and reactive to light, positive red reflex; tracks with eyes, nares patent and noninjected; posterior pharynx without redness or lesions; TMs noninjected, crisp cone of light, TMs mobile

Neck:  Supple no abnormal adenopathy

Respiratory: Clear to auscultation and percussion

Heart:  Regular rate and rhythm; no murmurs, rubs, or gallops

Abdominal:  No hepatosplenomegaly; abdomen soft, nontender

Neurological:  No head lag when pulled to a sitting position; rolls to side easily, pulls up to elbows; tracks objects with eyes, babbling

Extremities:  Femoral pulses 2+; full ROM of hips; no cyanosis, clubbing, or edema

Nutrition: Breastfeeding until 3 weeks ago; started on Similac and then switched to low-iron Similac; taking 4- to 5-oz bottles every 4 to 5 hours for 24 to 30oz of formula per day; has not yet had cereal or other solid food

Developmental:  Reports infant is smiling, babbling, able to hold head erect, can self-soothe, indicates pleasure/displeasure; rolls to side and from front to back; reaches for objects, puts hands in mouth, pulls up to elbows