Sim4Examination.docx - Medical History Reason for Seeking Care \u201cVomiting and water stools bad since yesterday night\u201d History of Present Illness

Sim4Examination.docx - Medical History Reason for Seeking...

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Medical History Reason for Seeking Care: “Vomiting and water stools, bad since yesterday night” History of Present Illness: Vomiting and watery diarrhea past 12 hours, following attendance at a family gathering where child consumed traditional Ukrainian foods. Abdomen “round like ball” with poor appetite and irritability, noted intermittently by parents over last 6 months, currently “worst ever”. No obvious blood in stool or emesis. Child crying without tear production last 6 hours. Mother reports 2 or 3 wet diapers and 8 to 10 additional diapers containing stool only in last 24 hours. Last loose stool and emesis within the hour. No fever, rash or other signs/symptoms noted. No other family members affected. No known exposure to GI illnesses. Parents attempted oral rehydration with honey-sweetened tea and cola, but child had minimal intake and persistent vomiting. Mother administered propolis tincture “in case of infection”. No other medications or treatments administered at home. Past History: Prenatal/Perinatal: Infant born in rural Ukraine at 37-38 weeks gestations to 28 year-old G5 P2/ 2-0-2-2 mother. Uncomplicated pregnancy; 4 or 5 prenatal visits with local midwife. No prenatal testing. No medications other than multivitamins during pregnancy. Birth and Neonatal Period: Spontaneous vaginal delivery at local clinic after 6 hour unmedicated labor. APGARS unknown, but baby “slow to cry”; needed vigorous stimulation and oxygen. Birth weight approximately 7 pounds. Discharged home with mother at 8 hours of age. Noted at birth to have physical characteristics consistent with Down syndrome; diagnosis confirmed by pediatrician in Kiev at 3 weeks of age. No other congenital anomalies or associated conditions identified at that time. Feeding History: Breastfeeding attempted but unsuccessful due to infant’s poor suck. Received iron-fortified infant formula until 12 months of age, then transitioned to whole milk. Currents eats family diet, but is “picky” eater with generally poor appetite. Growth and Development: Slow initial growth due to poor suck. Continues to be a poor eater per mother’s report. Refer to growth chart. Recently began to sit without assistance. Crawling and pulling to stand, but not walking as yet. Only intelligible word is “mama”. Mother notes significant developmental delays as compared with siblings. Has not had ongoing development assessment by a HCP.
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