A 12-month-old female patient new to your clinic schedules an

A 12-month-old female patient new to your clinic schedules an appointment with you to establish care after moving here from another state. The family prefers to take a more holistic approach to health which includes breastfeeding, vegetarian diet, and an alternate vaccine schedule; however parents do not have her vaccine records. The parents stated that the patient had a well child checkup four months ago. They don’t have any specific concerns but wanted to determine their daughter’s compatibility with you as a primary care provider. The parents brought her prior health records. Vital Signs: Temperature: 97.2° F Pulse: 145 beats per minute (bpm) Respirations: 28 breaths per minute Blood Pressure: 92/55 mmHg Pulse Oximetry: 93% on room air General Assessment: The child is content when held by mother, but irritable with assessment. She appears very thin and small for her age. Eyes: slightly sunken in, otherwise symmetrical in movement Mucous membranes: moist appearing Skin: Slight pallor, no obvious lesions Musculoskeletal: Moves all extremities Questions 1. When reviewing the records, what are the top 3 priority things you would look for to evaluate the patient’s growth and development? Provide a rationale for your choices. 2. Given the information you have, a problem list with at least 3 problems, based on the history and general assessment information. For each problem, provide a statement that you would inquire about with the parents. For example, the patient has had an alternate vaccine schedule. A relevant statement would be: “What type of alternate schedule do you use?”, “Is there a reason that you are using this alternate schedule?”. 3. Provide two strategies that would help you get the vaccines records for a patient who received vaccines in another state? 4. Using the Bright Futures Periodicity Schedule, what are the recommendations for her age? https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf 5. Now you are prepared to conduct a physical exam. What order would you assess each body system (i.e. auscultation, palpation, percussion and inspection). You were able to get the vaccine record which includes dTap (2 doses), Hib (2 doses), Polio (2 doses). These were given at 4 months and 6 months of age. The last well child checkup was the 6-month visit. When you confront the parents about the last visit being 6 months ago, not 4 months ago, they state that the provider insulted them about her feeding habits related to her daughter’s weight, so they didn’t want to return. Patient weight: 7.6 kg Patient height: 56 cm 6. What are the growth percentiles for this patient’s height and weight? How would you explain the data points to the parents when they ask if she is in a normal range? 7. When the parents remove the patient’s clothing, you observe her to be extremely thin. You inquire about frequency of breastfeeding and find that she breastfeeds every 1-2 hours. She does not supplement with pumped breastmilk or formula. You suspect that the mother is not producing enough milk. How would you determine the volume the patient is getting with a breastfeeding session? 8. Unfortunately, you determined that the mother is only providing 10 mL of breastmilk with each breast. What nutritional recommendations would make for this patient based on their preferences of vegetarianism? 9. You decide that the patient is at risk for vitamin D, iron, and fluoride deficiencies. Provide 3 prescriptions with all relevant information that you will electronically prescribe. 10. You realize that this family is resistant to health recommendations, but you would like to give the patient vaccines which are due for her age. The parents agree to do two shots. They just don’t want her to be poked with needles several times. Which 2 vaccines would you prioritize and why? The patient tolerated the vaccines you chose, and the family agrees to return in one month for a weight check and possibly additional vaccines

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