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Question #1 

Click here to view the Pediatric Case Study (Links to an external site.) and then post your responses to the following questions:

  • Give three (3) examples of both subjective and objective data for this case.
  • Include examples of pertinent positive and pertinent negative data associated with each.
  • Provide rationales for your example.  

Question #2A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.

  • Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
  • In SOAP format, list:
    • Pertinent positive and negative information
    • Differential and working diagnosis
    • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

      This is the transcript for the case study for question #1

Introduction

Mercy Garcia was diagnosed with celiac disease at about 11 months of age approximately four months after she started on solid foods. Mercy had a term birth at 39 4/7 weeks of gestation and an apgar score of 9. She developed normally until she began having GI symptoms and refused feedings.

Initial Conversation

Practitioner: Hi Mrs Garcia how is Mercy been doing?

Mom: just OK I’m worried about her celiac disease might not be under control. Do you think she’s developing OK? Is she gaining weight?

Observation

The practitioner observed that mercy had a small stature, much smaller than expected for her stated age of 30 months. Although she was quite slim, a prominent distended belly was evident.

Continuing Conversation

Practitioner: tell me about mercy’s activity level and diet

Mom: She’s active and likes playing in the kitchen, but she gets tired easily and is irritable until she rests. She eats well about half of the time, but often she’s just not hungry. She has painful belly gas every day

Practitioner: is there ever any blood in her stools?

Mom: No, I haven’t noticed any. She really wants to eat the same food as her dad and sister and me, but her tummy hurts, and sometimes she throws up after eating bread. Then she wakes up during the night. Usually she’s constipated, but sometimes she can get diarrhea after eating. Her poop smells so bad . This happens every time she eats anything that is not on the diet list that you gave me.

Chest Examination

As Mrs Garcia continued talking about her daughter, she rubbed Mercy’s head gently and played with her hair. Mercy’s chest was auscultated as she sat with her mother. Her heart tone were regular at 102, and no murmur , gallop, or heaves were noted . Her lungs were clear in all fields anterior and posterior.

Walking

Mercy said, “down”, then wiggled to get off her mother’s lap. She walked steadily to a toy box in exam room. She reached for a toy, turned it over and tried to turn a gear knob on the back of the toy, then she brought it back to her mother . As she walked to her mother, her thin legs and flat buttocks were visible.

Height and Weight

Measuring Mercy’s height and weight. Mrs Garcia removed Mercy’s clothing and placed her on the scale she weighed 9.5 kg, 1.8 percentile for age and gender, she measured 84 cms on the height board, 2.9 percentile.

Compared to her last visit measurements, she had gained weight, but she remains in the last percentile for both dimensions.

Laboratory Studies

Mom: Is mercy going to get diabetes? I saw on the Internet that type one diabetes is common with celiac disease.

Practitioner: Symptoms are different from one celiac child to another. We are going to monitor Mercy closely for any changes in her status . In fact, I’d like to do some lab work on her before you leave today.

Narrator: Laboratory studies were drawn to check for anemia and diabetes ( CBC and glucose) . Because celiac disease is a disease of severe malabsorption, we know by the foul stools that Mercy is losing fats in her stools, so a three day stool fat collection was ordered and the procedure was explained

Plan

Practitioner: Mrs Garcia, controlling the disease is the most important help that we can give Mercy. Her symptoms will clear if trigger foods are totally avoided. Over the coming years, Mercy will need to know how to choose gluten free foods because gluten is toxic to Mercy’s bowel. Everyone in the family can be part of helping to make life better for Mercy. Rather than concentrating on what Mercy cannot have, perhaps we could look at expanding the foods as she can have.

Narrator: Foods containing gluten were reviewed and an appointment with a nutritionist was made for the mother. Finally, referral back to the gastroenterologist was 

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