Birth history: Anita was the product of a 38‐week gestation. She was delivered via spontaneous vaginal delivery. Anita’s mother had no falls, infections, or known exposures to environmental hazards. The only prescription medications taken during the pregnancy were prenatal vitamins. She did not use alcohol, tobacco products, or illicit drugs during the pregnancy. Anita’s birth weight was 3250 g and her Apgar scores were 8 at 1 minute and 9 at 5 minutes. Her discharge weight was 3180 g.
Social history: Anita lives at home with her teenage mother and her maternal grandmother (MGM), who emigrated from Mexico. The father of the baby is involved. Neither parent has any other children. Both parents are students at a local high school. The family has a dog.
Family medical history: PGF (age 37): high blood pressure; PGM (age 33): thyroid problems; MGF (age 35): health history unknown; MGM (age 30): healthy; mother (age 15): healthy; father (age 15): healthy.
OBJECTIVE
Vital signs: Weight: 4050 g; length: 48 cm; temperature: 37.3°C (rectal).
General: Alert, well‐developed baby.
Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor.
Head: Normocephalic; anterior fontanel is open and flat (3 cm × 2 cm); posterior fontanel is open and flat (1.0 cm × 0.5 cm).
Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.
Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex.
Nose: Both nostrils congested; cloudy discharge present in nares; mild nasal flaring.
Oropharynx: Mucous membranes moist; no teeth present; no lesions.
Neck: Supple; no nodes.
Respiratory: RR = 24; lungs with clear breath sounds in all lobes; no retractions present; no grunting; no deformities of the thoracic cage noted.
Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally.
Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly.
Genitourinary: Normal female genitalia.
Back: Spine straight.
Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click.
Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes.
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Upper gastrointestinal (GI) imaging series___Manometry to assess esophageal motility and lower esophageal sphincter function___Complete blood count
2 What is the most likely differential diagnosis and why?___Overfeeding___Gastroesophageal reflux disease___Gastroenteritis
3 What is the plan of treatment and follow‐up care?
4 Does the patient’s psychosocial history impact how you might treat this case?
5 What demographic characteristics might affect this case?
6 Are there any standardized guidelines that should be used to assess or treat this case?
Case 2.1 Nutrition and Weight
By Mikki Meadows‐Oliver, PhD, RN, FAAN
SUBJECTIVE
Neil, a 12‐month‐old infant, presents to the office for a well‐baby visit. He is accompanied by his mother, Kayla. Kayla states that Neil has been healthy since his last well‐baby visit at 9 months of age. He has had no visits to the urgent care clinic or to the emergency room in the interim. Kayla is concerned that Neil’s appetite has diminished. She states that he is not eating as much lately as he had been.
Diet: Neil’s nutrition history reveals that he has successfully transitioned to a diet with whole milk. He drinks five 8‐oz bottles of whole milk daily. Neil is a “picky eater.” He rarely eats foods that are offered to him and, instead, prefers to drink from the bottle. He is not currently taking any multivitamins.
Elimination: Kayla states that Neil has 4–6 wet diapers daily. He does not have any diarrhea but does have occasional constipation that is relieved with prune juice.
Sleep: Neil sleeps 13 hours nightly but does not take any naps during the day. He does not have any problems falling asleep or staying asleep. His nighttime bedtime routine includes a bath and bedtime story read to him by Kayla.
Developmental: Neil is able to walk while holding onto furniture. He can also stand unassisted for about 5 seconds. Neil says “dada” and “mama” and has words for bottle and milk.
Birth history: Neil was the product of a 37‐week gestation. He was delivered vaginally with the assistance of a vacuum. During the pregnancy, Kayla had no falls or infections. She did not drink alcohol, take over‐the‐counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Neil’s birth weight was 3000 g, and his Apgar scores were 8 at 1 minute and 9 at 5 minutes. Past medical history reveals that Neil has had 3 episodes of acute otitis media since birth. He has had no injuries or illnesses requiring visits to the emergency department.
Social history: Neil was born to a 20‐year‐old mother. He has a 2‐month‐old younger sibling. He lives at home with his mother and his paternal grandmother. Neil’s father is currently incarcerated. Neil’s mother does not currently work outside the home. The family receives a rent subsidy from Section 8 and a food subsidy from the Women, Infants, and Children (WIC) program and food stamps.
The family also receives monthly cash assistance from the Temporary Aid to Needy Families (TANF) program. The family has no pets and there are no smokers in the home.
Family medical history: Neil’s mother has no health problems. His father is 32 years old and has no history of chronic medical conditions. His maternal grandmother has a history of breast cancer. His maternal grandfather has high blood pressure. His paternal grandmother (48 years of age) is healthy with no health problems. The health history of his paternal grandfather is unknown.
Neil is not currently taking any over‐the‐counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required
