GU: Angelina Torres

Subjective

Angelina Torres is a nine-month-old Mexican American

girl. For the past two and a half days, she has had a fever of 102 to 103 degrees F. She is not eating well and is generally fussy, but consolable. She has three siblings, none of whom are ill at the present time. She does not have any rashes, runny nose, cough, diarrhea, or vomiting.

PMH:

Angelina was born full-term, is at 50% for height and weight and has been growing and developing normally. She recently started eating more table food, in addition to baby cereals, vegetables, fruits, and meats. She drinks a soy-based infant formula. Her immunizations are up to date. Other than two mild URI’s between four and seven months, she has not been diagnosed with ear infections or any other significant childhood illnesses.

Objective

PE: Vital Signs: Wt. : 8.7 kg (19.0 lbs.), Length: 70 cm (27.5 inches), T: 39.4 degrees C

(102.9 degrees F).

General:

Well-nourished, alert, slightly fussy infant. Consoles easily. Feels warm to touch.

HEENT: Eyes are clear, with no redness or drainage. Tympanic Membranes are slightly obscured by cerumen, but the visible tympanic membranes have clear bony landmarks and are not inflamed.

There is no visible middle ear effusion. No nasal drainage. Oral cavity and pharynx show no inflammation or ulcers or exudates.

Chest: Mild tachypnea and tachycardia. Breath sounds are clear throughout. No

heart murmurs. No cyanosis.

Abdomen: Nondistended abdomen with active bowel sounds. Nontender

To palpation.

Labs: You collect a “bagged” urine specimen, which is moderately positive for

Leukocyte esterase, and negative for nitrates.

Assessment and Plan: Putting it all together:  Answer each question based on the case study above

1.Identify and discuss/analyze the most important

aspects of Angelina’s history. What important historical items are missing?

2. Identify and discuss/analyze the most important objective findings. What other objective data is missing that would help establish a diagnosis?

3. State your Assessment. List differential diagnoses for this patient (pretending you don’t know the given bagged u/a results).

4. Clearly state both a short-term and long-term plan of care for Angelina based on the given lab results (i.e., possible UTI). Include diagnostic testing, consults, referrals, patient education, and follow-up. Discuss the rationale for the measures contained in your plan, using evidence-based guidelines and other peer-reviewed, primary

academic references to support your rationale.

References

Gallegos, C., & Merkel, R. (2019). Current evidence in the diagnosis and treatment of children with celiac disease Gastroenterology Nursing: The Official Journal of the Society of Gastroenterology Nurses and Associates,42(1),41-48. DOI: 10.1097/SGA.0000000000000365

Garzon Maaks, D.L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., Duderstadt, K. G. (2020). Burns’ Pediatric primary care (7th ed.). St. Louis, MO: Elsevier Science. ISBN-13: 978-0323581967