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44 year-old Filipino patient came to have his “blood thinner” labs drawn, started them two weeks ago

Question
Answered step-by-step
Asked by MegaCapybara3167
Identify all pertinent positive and negative information.

 

Would there be any other information you would want to obtain? 

 

List 3 possible differential diagnosis with actual diagnosis based on your findings

 

What  is to your  plan of care utilizing clinical practice guidelines for the priority diagnosis. 
What state or federal resources are available to these parents?

      6.  What health promotion recommendations may you want to consider? 

C.C. 3-day old checkup 

HPI: Mother and Father present to clinic in Central Pennsylvania with their 3-day old son. 3 day old. M was born at home at 38 weeks’ gestation. Since his birth, mother has noticed poor feeding habits, very few sweet-smelling wet diapers and sleeping more. This was their 4th home delivery, 3 living children without any developmental or medical concerns. Have never experienced this behavior with their other children who are now 5, 4, 1. 

PMH: Born at 38 weeks’ gestation vaginally at home. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant is breastfed. The siblings are not vaccinated. 

Allergies: No known drug allergies 

Medications: None Social History: The infant lives with his mother, father, siblings and maternal grandparents. Live on a farm in Lancaster County. Mennonite. Mother stays at home with children and father works on the family farm/wood mill. The infant is not exposed to tobacco smoke. 

Family History: Mother and father deny any significant medical history. Siblings have no significant medical history and are not up to date on immunizations. 

Review of Systems 

General: Mother denies unexplained fevers. Concerned about increase sleep, weak suck and poor eating habits. 

Skin: The infant’s mother denies any rash or lesions. Head: Mother denies any trauma/forceps used in birth. 

ENT: Mother denies any concerns with the infant’s ears, nose, or throat. Neck: Mother denies any concerns with neck. 

CV: The infant’s mother denies any cyanotic spells or a discoloration of the skin.

 Lungs: The infant’s mother denies any cough, congestion, wheezing, or difficulty breathing. 

GI: Mother reports 1 bowel movements per day, dark in color. Denies meconium during birth. 

GU: Negative for diaper rash. Mother has reported decrease number of wet diapers and has noticed a sweet odor when changing cloth diaper.

Objective

 VS: Temperature: 99.7 F, HR: 161, RR: 52 Ht: 21 in, Wt.: 6lbs, 4.6 oz, HC: 46.1 cm 

General: Appears lethargic, sunken eyes, pale skin. Laying on table in “fencing” pose. 

Skin: No evidence of rash or lesions.

 Head: Normocephalic.

 Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally. 

ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Tip of otoscope sweet smell once removed from ear. Oropharynx: normal mucosa, palate, and posterior pharynx. Neck: Supple, no adenopathy. 

CV: Tachycardic and rhythm. Faint murmur noted. Femoral pulse 2+ bilaterally. 

Lungs: Increase respirations with nasal flaring, lungs clear bilaterally. 

Abd: Hypoactive bowel sounds. No masses or tenderness or organomegaly observed. 

GU: Penis: normal uncircumcised male. Testes descended with no inguinal hernia noted.

MSK: Poor tone and muscle strength. Negative for “hip click”

SCIENCE
HEALTH SCIENCE
NURSING
NU 632

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