Jane brings in her four-year-old named Tim

Jane brings in her four-year-old named Tim to a comprehensive pediatrics clinic in order to assess his health status. Jane reports that Tim is very curious and smart and gets along socially with other children. Jane says that Tim’s preschool teacher suggested she take him into the doctor for a health screening, because she has noticed his stools looking oily when he uses the bathroom. Patient History: Tim’s mother Jane is a former drug user and has no family in the area. For these reasons, along with the socioeconomic status of his household (below the poverty line), Tim had a difficult first few years of life. However, recently his mom got help from social services and has been drug-free for six months. They are living in a new rental home and Tim is adjusting well to his new living situation but is still struggling at school. He recently had several accidents and so they temporarily put him in pull-up diapers. He has also shown to be hesitant in engaging in physical activity and seems more tired and exhausted than a typical four-year-old should be. Measurements & Vital Signs : Age: 4.5 yrs Height: 3 ft. 7 inch Weight: 32 lbs. Pulse: 108 bpm Respiratory Rate: 30 breaths/min Temperature: 99.1 degrees F Blood pressure: 100/55 mmHg Physical Exam: General appearance: Good-natured, active, secure Ear, Nose & Throat: Runny nose. Ears do not show sign of infection Abdominal: Normal; no pain reported upon touching Neuro: Normal Respiratory: Cracking/wheezing sounds; slight cough Cardio: Normal Nails: Nails: normal in color but nail beds are slightly curved 1. Objective: This is the diagnosis of the patient – find the diagnosis listed as the admission diagnosis if the discharge diagnosis different from the admission diagnosis write both here. 2. Plan: what plan does the patient have include referrals, medications etc… 3. Assessment: all labs, test and any procedure done to make an assessment for the diagnosis 4. Subjective: This is everything that the patient describes (you may also want to research to see what other symptoms patient may have had for the diagnosis) SCIENCE HEALTH SCIENCE NURSING MOA 182

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