Episodic Case Study Assignment Paper

Patient information

Patient initials:  P.T          Age:9 months                  Gender: Female                 Race: Hispanic

S.

CC: “Vomiting and diarrhea”

HPI: P.T, a 9-month-old Hispanic girl, was brought to the clinic by her father and mother with the chief complaint of vomiting and diarrhea, which her father reported had been going on for 5 days. The patient’s father reported that the problem began after she was switched from taking Mexico milk branded as Nan to a comparable but more modern standard formula. The father also reported that patient can consume solid food, but afterwards vomits and has diarrhea. No headache, or chronic cough were reported. Episodic Case Study Assignment Paper

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Current Medication: Acetaminophen syrup prn

PMH: No past medical history was reported

Family Hx: Non-contributory

Allergies: the patient has no known food or drug allergy

Social Hx: The patient is the third born in the family of three. His father, mother and two sisters just moved to united state from Mexico. No alcohol and tobacco used reported.

ROS

Constitutional: No weight loss, fever or chills was reported.

HEENT:  No changes in vision or hearing was reported.

Resp: No SOB and chronic reported.

Skin: No skin lesions, facial flushing or rash reported.

Cardiovascular: No palpitations, chest pain, pallor tropic changes, or dyspnea reported.

Gastrointestinal:  vomiting and diarrhea were reported. Abdominal pain was not reported.

Endocrine: No issue with weight loss, heat or cold intolerance were reported

Genitourinary: No oliguria, frank pain, dyspareunia or polyuria reported

Musculoskeletal: No issue with arthralgia, back pain was reported.

Neurological: No headache or pruritis was reported.

Psychiatric: no changes in mood, anxiety or depression was reported. Episodic Case Study Assignment Paper

Objective

PE:

Vts: Wt.171lb length 27.5 temp 98.6f

General appearance: The patient is alert, well nourished. Appear her stated age.

HENT: head normocephalic and atraumatic. EOMI, no buccal nodules noted.

Skin: Patient skin is dry, and intact without any lesions and is the color is appropriate for ethnicity.

Abdomen: protuberant, with bowel sound hyperactive in all quadrants. No tenderness noticed on palpitation.

MS: extremities are all in normal strength and function.

A

Lab Test and Result

Complete blood count (CBC): to measure electrolytes, result pending

Stool test: To verify the parasite causing the disorder. Result pending

Diagnosis

K59.1 – Functional Diarrhea

Functional diarrhea is a fairly common condition in children, and is characterized by episodes of diarrhea that are not caused by any other medical condition. Functional diarrhea typically lasts for several days or weeks and is generally milder than acute gastroenteritis, which is the most common form of diarrhea (Vecchio et al.,2021)Episodic Case Study Assignment Paper. Functional diarrhea can be caused by a number of different factors, including infection with bacteria or protozoa, food poisoning, and Crohn’s disease.

R11.2 – Nausea with Vomiting, Unspecified

Differential diagnoses

Glucose-galactose malabsorption

Glucose-galactose malabsorption is an inherited condition in which the body is unable to absorb glucose and galactose, two simple sugars that are found in milk and other foods. People with this condition experience diarrhea, and bloating after consuming milk or milk products (Lostao et al.,2021). The condition is caused by a mutation in the gene that codes for a protein called lactase. It’s a common problem, affecting up to 5% of infants and children. The condition can cause significant health problems, including growth problems, development delays, and health problems related to digesting food. This could be a patient diagnoses owing to her father remarks on changing the nun-milk formulation to a more advanced one.

  Acute Gastroenteritis

Acute gastroenteritis is a medical condition that results in the inflammation of the stomach and intestines. This condition is most commonly seen in children, although it can affect people of all ages. The symptoms of acute gastroenteritis can vary depending on the individual, but typically include diarrhea with or without nausea, fever and abdominal pain (Szajewska et al.,2019)Episodic Case Study Assignment Paper. This condition is often self-limited but in severe cases, can lead to complication such as dehydration and malnutrition.

Motion sickness

Travel or motion sickness is a medical condition characterized by diarrhea, nausea and vomiting and often common in infant due to * perceived conflict between visual and vestibular system which is underdeveloped in infants (Lacy et al.,2022). It’s also a possible diagnosis to the child based on the fact that they have just moved to US from Mexico but it often last only for hours after landing to targeted destination which was not the case for the patient.

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Plan:

Tx plan

The parents urged to discontinue the new formula and substitute it with Pedialyte and baby oatmeal for 2 days. The infant formula got changed to Maximum Comfort. Informed parents to go to WIC to pick up formula. To come back to the clinic if problems intensify. Refer to gastroenterologist in cases of complication.

Patient Education:

Diarrhea is a frequent newborn disease that can be caused by a variety of factors. The most prevalent cause of newborn diarrhea is rotavirus. Bacteria, parasites, and dietary allergies are all possible reasons of diarrhea. Supportive care, particularly appropriate hydration, is the cornerstone of therapy. It is critical that patient parents understand the importance of newborn feeding and formula selection. They must be urged to feed their child with lots of water and to wash their hands often Episodic Case Study Assignment Paper.

References

Lostao, M. P., Loo, D. D., Hernell, O., Meeuwisse, G., Martin, M. G., & Wright, E. M. (2021). The molecular basis of glucose galactose malabsorption in a large Swedish pedigree. Function, 2(5), zqab040.

Lacy, B. E., & Cangemi, D. (2022). Approach to the patient with nausea and vomiting. Yamada’s Textbook of Gastroenterology, 577-598.

Szajewska, H., Kołodziej, M., Gieruszczak‐Białek, D., Skorka, A., Ruszczyński, M., & Shamir, R. (2019). Systematic review with meta‐analysis: Lactobacillus rhamnosus GG for treating acute gastroenteritis in children–a 2019 update. Alimentary pharmacology & therapeutics, 49(11), 1376-1384.

Vecchio, A. L., Conelli, M. L., & Guarino, A. (2021). Infections and chronic diarrhea in children. The Pediatric Infectious Disease Journal, 40(7), e255-e258. Episodic Case Study Assignment Paper

Patient Demographics

Age:

9 months
Race:

Hispanic
Gender:

Female

pt has father, mother, two sisters and just moved to United States from Mexico

Type of Decision-Making: Low complexity
Student Participation: Primary (>50%)
Reason for Visit: Episodic
Chief Complaint: vomiting and diarrhea
Encounter #: 1
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-10 Diagnosis Codes
#1 – R11.2 – NAUSEA WITH VOMITING, UNSPECIFIED
#2 – K59.1 – FUNCTIONAL DIARRHEA
CPT Billing Codes

Medications

# OTC Drugs taken regularly:

0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Analgesic/Antipyretic – Acetaminophen combinations
GI Agents – Miscellaneous GI
Adherence Issues with Medications: Episodic Case Study Assignment Paper

Clinical Notes

weight 17lb length 27.5 temp 98.6 f

pt arrived to clinic with mother and father. mother is Spanish speaking. father speaks English. pt father states the pt has had vomiting and diarrhea for five days. The patient was on a milk from Mexico called Nan. Parents switched formula to Similac advanced and the patient start vomiting and diarrhea as result. pt father states she is able to eat solids but vomits and diarrhea shortly after.

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instructed parents to stop formula and start the baby with Pedialyte and baby oatmeal for two days. switched the baby formula to total comfort. instructed parents to go to WIC to pick up formula. If symptoms persist or worsen to come back to clinic.

please use this patient as soap note/ episodic case study. Episodic Case Study Assignment Paper