Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out Diagnostic plan with supporting rationale or references A specif
- One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
- Brief introduction of the case
- Identification of the main diagnosis with supporting rationale
- Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
- Diagnostic plan with supporting rationale or references
- A specific treatment plan supported by recent clinical guidelines
Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric:
Aquifer Case Study Week 1 Pediatrics 01: Newborn male infant evaluation and care
United States University
FNP 593: Primary Health of Acute Clients/Families
Across the Lifespan
Dr.
March 06, 2023
Case Analysis Tool Worksheet
Student's Name: Case ID: Molina_AQ1_03062023
I. Epidemiology/Patient Profile
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Rose, a 20-year-old female at estimated 38 weeks' gestation financially insecure, unemployed, medically uninsured and estranged from her family. She is in active labor with ruptured membrane. |
II. Prioritized Cues from Hx and PE. (Do not include lab, x-‐ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
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Membranes ruptured |
Food unsecured |
No history of sexually transmitted disease |
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Sex with four men |
Smokes marijuana occasionally |
Tylenol as needed |
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Smoke cigarettes two or three a day, one drink a week |
BP 115/70 |
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Has history of asthma |
UA negative protein. |
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Has no job, live with friends |
No ankle swelling |
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Nulliparity |
Denies abdominal pain or vision changes. |
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Age: 20-year-old |
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Failure to obtain normal medical care during pregnancy |
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Lower socioeconomic status |
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No prenatal vitamins |
III. Problem Statement
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Rose, a 20-year-old woman being admitted to obstetrics from the emergency room, gave birth to a newborn boy. Based on her LMP, Rose is 38 weeks pregnant. She is expecting her first child and is currently in active labor with ruptured membranes. Because she lacks insurance and is unemployed, Rose reports having several partners for sex and not receiving prenatal care. Rose adds that she has cut back on smoking, now only consumes a few beers on the weekends, and occasionally puffs on some marijuana. During physical examination, the patient had a blood pressure of 115/70 mm Hg, a fundal height of 33 cm, fetal heart tones of 135 bpm, and negative protein and glucose results from urinalysis (UA). She says that until today, she had not experienced any headaches, vision abnormalities, or ABD pain. Apart for sporadic Tylenol when pregnant, she does not currently use any drugs. |
IV. Differential Diagnosis
Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient’s complaint(s).
List your most likely diagnosis first, followed by two other reasonable possibilities. For some cases, fewer than 3 diagnoses will be appropriate.
Then, enter the positive or negative findings from the history and the physical examination that support each diagnosis.
Leading dx:
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Intrauterine Growth Restriction (IUGR) ICD-10, P05.08 |
(Sacchi et al., 2020)
History Finding(s) Physical Exam Finding(s)
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Young maternal age 20 |
Baby boy Thomas is small in size. Weight 2100 grams Weight below 10th percentile Length 43 cm Head circumference 32 cm (normocephalic) |
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With a mother who has history of alcohol and tobacco use during pregnancy |
A mother in active labor and ruptured membranes Five-minute Apgar score is 9 |
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Failure to obtain normal medical care during pregnancy |
Fundal height: 33 cm Fetal heart tones: 135 bpm Temp: 36.9 C Respirations: 44 |
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Lower socioeconomic status |
Blood glucose: 50 mg/dL (2.8 mmol/L) |
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No prenatal vitamins |
Negative HIV antibody Hepatitis B surface antigen, RPR, urine NAAT for chlamydia and gonorrhea, UA protein |
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Poor nutrition and weight gain |
Thomas physical exam is unremarkable |
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Pink centrally but still has acrocyanosis, APGAR score of 9 |
Alternative dx:
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Congenital Infections (P37.9) |
(Moodley & Payton, 2021)
History Finding(s) Physical Exam Finding(s)
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No prenatal care |
Baby boy Thomas is small in size. Weight 2100 grams Weight below 10th percentile Length 43 cm Head circumference 32 cm (normocephalic) |
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Lower socioeconomic status |
A mother in active labor and ruptured membranes Five-minute Apgar score is 9 |
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Poor nutrition and weight gain |
Fundal height: 33 cm Fetal heart tones: 135 bpm Temp: 36.9 C Respirations: 44 |
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Alcohol and tobacco use during pregnancy |
Blood glucose: 50 mg/dL (2.8 mmol/L) |
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Negative HIV antibody Hepatitis B surface antigen, RPR, urine NAAT for chlamydia and gonorrhea, UA protein |
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Thomas physical exam is unremarkable |
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Pink centrally but still has acrocyanosis, APGAR score of 9 |
Alternative dx:
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Placental Insufficiency |
(Mohan et al., 2018)
History Finding(s) Physical Exam Finding(s)
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Young maternal age 20 |
Baby boy Thomas is small in size. Weight 2100 grams Weight below 10th percentile Length 43 cm Head circumference 32 cm (normocephalic) |
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Failure to obtain normal medical care during pregnancy |
A mother in active labor and ruptured membranes Five-minute Apgar score is 9 |
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Drinks beer on weekends |
Fundal height: 33 cm Fetal heart tones: 135 bpm Temp: 36.9 C Respirations: 44 |
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Unemployed, uninsured, no family support |
Blood glucose: 50 mg/dL (2.8 mmol/L) |
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Negative HIV antibody Hepatitis B surface antigen, RPR, urine NAAT for chlamydia and gonorrhea, UA protein |
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Thomas physical exam is unremarkable |
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Pink centrally but still has acrocyanosis, APGAR score of 9 |
V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
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Fundal height |
After the 20th week of pregnancy, the centimeter measurement usually corresponds to the remaining weeks of the pregnancy. A fundal height lag of 4 cm or more is suggestive with IUGR (AIMU, 2018). |
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Blood test: Complete Blood Count |
To test for anemia and polycythemia, which are both IUGR consequences (Balest, 2021). |
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Prenatal ultrasound |
To diagnose IUGR and obtain measurement of the baby |
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Doppler assessment |
It is a technique that uses sound waves to measure the amount and speed of blood flowing through the arteries. This examination will look at the blood arteries in the baby's brain and the flow of blood through the umbilical cord. Doppler tests that are abnormal are a sign of IUGR (AIMU, 2018). |
Treatment Plan Rationale
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Encourage good nutrition and bedrest for mother |
Better feeding and oxygenation may help a fetus with inadequate growth. With bed rest, it is believed that the mother's organs will function more efficiently. |
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Close monitor of the baby especially baby’s weight |
To ascertain whether the baby is gaining weight. Monitor and assess weight gain. |
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Erythromycin ophthalmic eye ointment (0.5 %) |
Preventive eye care for newborns to avoid gonococcal ophthalmia (Hanley, 2019). |
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Vitamin K 1mg IM at birth |
Vitamin K should be given at birth to prevent any potentially fatal effects. Within the first week of lifes, bleeding due to a deficit happens (Hanley, 2019). |
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Educate on breastfeeding and support groups Feeding on demand |
feeding to maintain a baby's weight. Breastfeeding guidance can be provided by a certified lactation counselor (Kellams, 2020). |
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Educate for alcohol and tobacco cessation |
Alcohol is transmitted in very small amounts to breast milk. Waiting two hours after consuming one serving of alcohol (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor) will help breastfeeding mothers avoid exposing their babies to alcohol (Kellams, 2020). Compared to other babies, infants who inhale secondhand smoking after birth have higher lung infections (Smokefree, n.d.). |
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Educate for normal feeding, stooling, urine output |
Energy and willingness to feed are important for the normal growth and development of a newborn (Hanley, 2019). |
References
American International Medical University (2018). Intrauterine growth restriction (IUGR): Symptoms, causes, diagnosis, management, complications & prevention. https://www.aimu.us/2018/01/15/intrauterine-growth-restriction-iugr-symptoms-causes-diagnosis-management-complications-prevention/
Balest, A. L. (2021). Small-for-Gestational-Age (SGA). Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/pediatrics/perinatal-problems/small-for-gestational-age-sga-infant
Hanley, J.R. (2019). Infant care. https://online.epocrates.com/diseases/130711/Infant-care/Overview
Kellams, A. (2020). Breastfeeding: Parental education and support. https://www.uptodate.com/contents/breastfeeding-parental-education-and-support?search=newborn%20care&topicRef=5068&source=see_link#PATIENT_INFORMATION
Mohan, R., Baumann, D., & Alejandro, E. U. (2018). Fetal undernutrition, placental insufficiency, and pancreatic β-cell development programming in utero. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 315(5), R867–R878. https://doi.org/10.1152/ajpregu.00072.2018
Moodley, A., & Payton, K. S. E. (2021). The Term Newborn. Clinics in Perinatology, 48(3), 485–511. https://doi.org/10.1016/j.clp.2021.05.004
Sacchi, C., Marino, C., Nosarti, C., Vieno, A., Visentin, S., & Simonelli, A. (2020). Association of intrauterine growth restriction and small for gestational age status with childhood cognitive outcomes. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2020.1097
Smokefree. (n.d.). Secondhand smoke. Babies who breathe secondhand smoke after birth have more lung infections than other babies.
I have adhered to the honor system:
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Aquifer Essay Title
Your Name
United States University
Course name
Instructor name
Date
Aquifer Essay Title
The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long.
Differential Diagnoses
This section will identify your two differentials with the rationale and supporting evidence. Also explain why these differentials were not the main diagnosis.
Diagnostics
Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing.
Treatment, Education, and Follow-Up
This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate.
References
The supporting evidence for this paper should be derived from at least two primary sources (not Medscape, UpToDate, Epocrates, etc.), including published clinical guidelines or peer-reviewed professional journals that are NOT textbooks. Supporting evidence should be published within the past 5 years, or 10 if the guidelines have not been updated. References should be in APA format. Refer to the APA 7 Manual for specific formatting requirements.
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