Mercy NURS775 Infant Case Studies Latest 2022

Case Study         #1_________________________________________________

 Informant:          Mother- Tammy Smith  18 year old Haitian female

Patient:                                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 child

NSVD 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 premie

Mother                                                18 years + history of ?  Asthma as a child

Father                                   19 years “Healthy”  (Has 3 other children by 2 different  women)

MGM:                                   35 years, HTN, Obesity

MGF:                                     Died of unknown cause at age 28 years

Maternal Aunts:                              ages 20 – Asthma

                                                                17 –healthy

Father’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 noised

-          rhinorrhea; 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 shoulder

Physical 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 arms

HEENT: Head: Normocephalic, AFOF 2.5 cm x 2.3 cm,

                                + good head control, lifts head when placed on abdomen

Eyes + red reflex, - discharge, follows past mid-line, + occasional beats of nystagmus noted

                                Ears: symmetrical, canals patent, no pits or ear tags

Nose + patent nares, no d/c, no rhinorrhea

                                Mouth + moist mucous membranes, good suck, palate intact, + gag reflex

Chest:                   Lungs clear to auscultation bilaterally

CV                           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 masses

GU:                        Labia Major with mild swelling, labia minora visible, urethra midline, + mucoid vaginal discharge

MS:                        - Ortalani/Barlow, moves all extremities freely

Neuro:                  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 care

o   Immunizations

o   Screening

o   Nutrition

o   Sleep

o   Elimination

o   Anticipatory guidance

o   Social Determinants of health

o   Referrals

o   Follow up

Case Study  #2________________________________________________

 Informant:         Ms. Adams; Mother

Patient:                4-week-old Timothy

Interval History:              4 week old male infant presents with mother 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 mother stating he looks a little yellow lately and she is worried about it, no N/V/D; 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 has no involvement with baby

                                Baby receives Medicaid

Family History:

                                Mom     16 yr.-healthy

                                Father 16 yr. healthy

                                MGM:     34 years- diabetes

                                MGMF   36 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: NCAT,

Eyes: Bilateral eye redness started 2 days ago, with some crusting this morning

No discharge seen,

Nose: slight rhinorrhea,

Ear, no ear d/c,

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           T  99.9, HR 136 RR: 40

                Ht: 52 cm

                HC  38 cm

                Wt. 4.3 kg