Reference no: EM133640666

Subjective:

Jack is a 12 month-old infant, presents to the office for a well-baby visit. He is accompanied by his mother, Kim. Kim reports no new issues since his last visit. She reports no visits to the urgent care or to the ER Kim is concerned that Jack's appetite has diminished. She states that he is not eating as much as lately as he had been. Jack's nutrition history reveals that he has successfully transitioned to a diet with whole milk. He drinks five 8-oz bottles of whole milk daily. Kim reports that Jack is a "picky eater." He rarely eats foods that are offered to him, and instead prefers to drink from the bottle. He is currently not taking any multivitamins.

Kim states that Jack has 4 to 6 wet diapers daily. He does not have any diarrhea but does have occasional constipation that is relieved with prune juice. Jack sleeps 13 hours nightly but does not take any naps during the day. He does not have any problems falling asleep or staying asleep. His nighttime bedtime routine includes a bath and bedtime story read to him by Kim. Jack is able to walk while holding onto furniture. He can also stand unassisted for about 5 seconds. Neil says "dada" and "mama" and has words for bottle and milk. Jack was the product of a 37-week gestation. He was delivered vaginally with the assistance of a vacuum. During the pregnancy, Kim had no falls or infections. She did not drink alcohol, take over-the-counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Jack's birth weight was 3000 g, and his Apgar scores were 8 at 1 minute and 9 at 5 minutes. Past medical history reveals that Jack had 3 episodes of acute otitis media since birth. He has had no injuries or illnesses requiring visits to the emergency department.

Objective:

Jack's vital signs were takin in the office. His weight is 6.4 kg, and his length is 66 cm. His temperature is 36.8 C temporal. When observing Jack's' general appearance, he is alert, active and playful. He appears well-hydrated and well-nourished. No skin issues noted. No cyanosis and/or diaphoresis noted. Jack's head is normocephalic. His anterior fontanel is open and flat (0.5 cm x 0.5 cm). Red reflex is present bilaterally; and his pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal, and the tympanic membrances are gray bilaterally, with positive light reflexes. Bony landmarks are visible, and there is no fluid noted behind the tympanic membrane. Both nostrils are patent. There is no nasal discharge, and there is no nasal flaring. Neil's mucous membranes are noted to be moist when examining the oropharynx. He has 8 teeth present, with white spots present on both upper central incisors. There are no lesions present in the oral cavity. Jack is able to move in all directions without resistance.

Shotty nodes present in the posterior cervical region. Lungs CTA b/l. No retractions or grunting noted on exam. No deformities noted to chest. No respiratory distress noted. HR is 106 bpm with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2+ bilaterally. Normoactive bowel sounds are present throughout; soft and nontender. There is no evidence of hepatosplenomegaly. Normal male genitalia. Jack is circumcised and his testes are descended bilaterally.

Good tone in all extremities; full range of motion in all extremities. His extremities are warm and well-perfused. Capillary refill is less than 2 seconds, and his spine is straight.

a) Which laboratory tests should be ordered as part of a 12-month, well-child visit?

b) Other than "well child", what additional diagnoses should be considered this visit for Jack?

c.) What is the plan of treatment, referral, and follow-up care?

d.) Does this patient's psychosocial history affect how you might treat this case?

e.) What would be different if this family lived in a rural setting?

f.) Are they any demographic characterisitcs that might affect this case?

g.) Are there any specialized guidelines that should be used to assess or treat this case?

h.) What anticipatory guidance should be given to the parent?

i.) Are there any immunizations due this visit?