Aquifer Case Study: Family Medicine Pediatrics #1
United States University
FNP 591: Common Illnesses Across the Lifespan Dr. Medina
July 4, 2022
Family Medicine Pediatrics 01
The most likely diagnosis for Thomas is Small for Gestational Age-related to poor maternal nutrition and...
The most likely diagnosis for Thomas is Small for Gestational Age-related to poor
maternal nutrition and weight gain (ICD-10 P05.1). As his mother is a G1P1, unemployed, and
estranged from her family, Thomas’ father is not involved, only received one prenatal visit,
fundus measured 33 cm at an estimated 38-week gestation based on her last menstrual period,
and had limited weight gain during pregnancy. Thomas’ weight was 2100 g at birth placing him
in below the 10th percentile on the growth chart which makes him small for gestational age
(Garzon et al., 2020). Infants that are small for gestational age are more at risk for hypoglycemia
and hypothermia and will require serum glucose level testing and frequent pulse oximetry
(Garzon, et al., 2020).
All newborns are encouraged to receive routine procedures such as prophylactic eye care
of erythromycin ointment to prevent neonatal gonococcal ophthalmia, hepatitis b vaccination,
intramuscular vitamin K to prevent bleeding, monitoring for hyperbilirubinemia and
hypoglycemia, and newborn hearing including hearing screening, and metabolic, genetic, and
congenital infections with blood spot testing (McKkee-Garrett, 2022). According to Garzon et
al., 2020, the USPST recommend prenatal screening, promoting breastfeeding, screening
neonates for sickle hemoglobinopathies, screening for congenital hypothyroidism, and screening
for phenylketonuria, screening for hip dysplasia, and topical ocular prophylaxis at birth.
Upon discharge, Thomas and his mother should be provided with resources and
education. Postnatal parental education should include the importance and benefits of
breastfeeding along with resources to lactation support, appropriate frequency of wet and dirty
diapers, umbilical cord, skin, and genital care, and recognition of neonatal illness and when to
return to the doctor or emergency room (McKkee-Garrett, 2022). She should also be educated
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