Toor Noori

H&P #2

Rotation 7 – Pediatrics

Location: Premier Pediatrics, Staten Island NY 10309

Date: 10/14/2019

Identification: 2 months old Caucasian female

Source of Info: Mother and Father

 

CC: “Well Visit exam and vaccinations”

Patient scenario

2month old Caucasian female, with no significant medical history, presents to the office with her mother and father for her 2month well exam and vaccinations ( HIB, DTAP, rotavirus vaccines). Mom states the child has been feeding and growing well, however she has been worried about her baby because “she is very fussy and spits up a lot”. She explains the child spits up 4-5 times a day, after feeds, and sometimes turns blue in the face. The child also becomes stiff with her back arched during these episodes. She has had four episodes in the past month and usually returns to normal within a 1-2 mins after the episode subsides. Mother reports two of those episodes consisted of projectile vomiting both occurring after her nighttime feedings, but on different days. Mom also explains the baby cries a lot after feeds and wants to be held and backwards positions where her arms are wrapped around the child’s stomach. She claims the baby appears to be more comfortable in this position. Patient is on Enfamil infant formula and drinks about 4 ounces of formula every 3-4 hours. Mother denies the baby has had any, diarrhea, blood in the stool, weight loss, coughing, feeding refusal, wheezing or signs of lethargy.

Happy spitter/ colic and gas

Gastroesophageal reflux

Eosinophilic esophagitis

Intestinal malrotation

Pyloric stenosis

PMHx:

none

Immunizations:

Hep B	8/7/19, 9/07/19
DTap	10/14/2019
Hib	10/14/19
Rotavirus	10/14/2019

Past surgical hx:

denies past surgeries, injuries or blood transfusions

Past hospitalizations:

denies past hospitalizations

Medications:

none

Allergies:

no known seasonal, drug or food allergies

Family history

Mother Father Grandfather (maternal) Grandmother (maternal) Grandfather (paternal) Grandmother (paternal)

33 years old, alive and well, no significant past medical history 35 years old, alive and well, no significant past medical history 60 years old, alive and well, no significant past medical history 58 years old, alive and well, no significant past medical history 62 years old, alive and well, no significant past medical history 58 years old, alive and well, no significant past medical history

Social Hx:

Healthy female who has been meeting her developmental milestones. She lives at home with her 2 parents, no siblings and frequently spends time with her grandparents. Moms on maternity leave but will be returning to work in a few weeks after which she will stay with her grandmother who is going to move in with them.

Neonatal Hx: Birth weight 6pound 14 ounces, length 20.07in, 39wks gestation, Normal Vaginal Delivery

Feeding History:

Bottle feeding Enfamil 4 ounces every 3-4 hrs

Developmental milestones:

Gurgling sounds: yes; Alert – yes;  Pays attention to surroundings: yes; Looks up at people: yes; Holds head up in prone position– yes;  Smiles – yes; Responds to loud sounds: yes.

ROS

Weight – denies recent changes in weight

Skin and Lymph – denies rashes, adenopathy, lumps, bruising and bleeding, pigmentation changes

HEENT – denies concussions, unusual head shape, strabismus, conjunctivitis, visual problems, hearing, ear infections, draining ears, cold and sore throats, tonsillitis, snoring, apnea, oral thrush, epistaxis

Cardiac – denies cyanosis and dyspnea, heart murmurs

Respiratory – denies pneumonia, bronchiolitis, wheezing, chronic cough, sputum, hemoptysis

GI –c/o spitting up and colic/fussiness after feeds. denies diarrhea, constipation, vomiting, hematemesis, jaundice, dark stool

GU – denies frequency, dysuria, hematuria, discharge, polyuria, previous infections, facial edema

Allergy – denies urticaria, hay fever, allergic rhinitis, asthma, eczema, drug reactions

 

Physical Exam

General appearance

Pt is alert, she appears well-developed, well-groomed and well-nourished. Appears in no apparent distress.

Vitals

Temp: 98.6

Weight : 11.4 pounds, 50 percentile

Height : 22.5 inches, 50 percentile

Head circumference: 39.0cm 25th percentile

Skin Head Eyes Ears Nose Mouth/Throat Neck Nodes Lungs Heart   Abdomen Extremities Back/Spine Genitalia Rectal Neuro

Warm and pink, no rashes, no cyanosis, pigmentations/petechiae/infections no trauma, PERRL, extraocular movements intact, conjunctivae clear, red reflex bilaterally, no evidence of strabismus Ear canal clear, TMs translucent and mobile, pinna ossicles normal appearance No deformities, nares patent, breathing through both nares Mucous membranes moist, no mucosal lesions Good tone, no adenopathy or masses Unremarkable cervical/epitrochlear/axillary/femoral lungs clear to auscultation, no retractions/abdominal breathing No cardiomegaly or thrills, regular rate and rhythm, no murmur or gallop, radio-femoral pulses – present and palpable simultaneously non distended, normal BS , no tenderness, organomegaly, masses, or hernia No deformities, full range of motion, no clubbing/cyanosis straight, FROM, no tenderness urethral meatus patent, no rash, no discharge patent, no anal fistula, no rashes Alert, respond to stimulus, stepping reflex intact

 

Assessment:

5month old Caucasian female with medical history no PMHx, presents to the pediatrics outpatient clinic with her mother and grandmother for scheduled well visit exam and due for 2month old shots -HIB, ROTA, and DTAP. Patient has been feeding well, stooling/voiding normally. The mother has concerns about child having spit up episodes. On physical examination there are no abnormal findings and otherwise infant is growing according to the developmental milestone (smiling, paying attention to surroundings, making sounds, lifts head up when placed in prone position).

 

Management/Plan

-Reassure parent that Most regurgitation resolves spontaneously by the end of the first year of life and requires no pharmacological intervention.

-Advise parents to continue to monitor the child for recurrent spit up episodes.

-Advise parents to reduce feeding volumes and offer more frequent feeds

-Advise parents on changing the infant’s body position while awake. Keep baby ins prone and left side down positions since they are associated with fewer reflux episodes but emphasize they should be done after feedings in only when child is awake/observed.

-Counsel parents on SID,  car seat safety, dangers of placing child in the same bed,

-Follow up appt  1 week to see how the child is responds to changes made. Come in sooner if symptoms are not improving or getting worse.

– Explain next step. If episodes continue, then may consider changing over to a hydrolyzed or amino acid formulas which may reduce reflux episodes in infants with allergies to cow’s milk protein.

– If all conservative treatment fails, we may consider, using acid suppression therapy with histamine H2 receptor antagonists (cimetidine 10-20 mg per kg per day divided by every 6-12 hours)  or proton pump inhibitors (PPIs).

-Follow up at 3 months for vaccinations and well exam.

Parent Education:

Your child may have something called gastroesophageal reflux.

Infantile gastroesophageal reflux may present with frequent regurgitation or vomiting, postprandial irritability, prolonged feeding or feeding refusal, or back arching.

Most regurgitation resolves spontaneously by the end of the first year of life and requires no pharmacological intervention.

Sleeping infants should always be placed in the supine position to prevent sudden infant death syndrome.

Never put your child to sleep in the same bed as you.