Week 2: Discussion Question – Clinical Experiences Discussion Responses

Please respond to the 2 following discussion posts separately with separate reference lists. References to be no older than 5 years.
1. Brian Marshall posted Sep 8, 2022 10:50 PM
Week 2: Discussion Question – Clinical Experiences
This week in clinical, one case that really stands out to me is the case of a premature infant, adjusted age of 1 month and three days, with a two-week history of inability to keep down any formula. Per mother and father this infant was unable to keep down any PO intake for the last two weeks, any intake at all would cause vomiting and the infant would act hungry after the vomiting spell. These findings were very concerning as the infant had lost weight when assessed by the medical assistants signaling marked malnutrition.
My preceptor’s and my main concern was pyloric stenosis. This pathology requires prompt surgical intervention to correct and spare the nutritional status of the infant. Given our serious concern we ordered stat labs to assess chemistry and blood count, we also sent for stat abdominal ultrasound to assess for outlet obstruction in the stomach.
Fenstermacher and Hudson describe abdominal ultrasound as the most sensitive and specific test to assess for presence for pyloric stenosis (Fenstermacher & Hudson, 2019). Maaks et al. describe the standard treatment for pyloric stenosis to be pyloromyotomy (Maaks et al., 2019). After surgical correction prognosis is typically excellent for these patients.
Pyloric stenosis was the most invasion and time sensitive diagnosis on our differential list, GERD, and gastroenteritis were also on the differential list. Given the nature of presentation we did the workup for pyloric stenosis first, gastroenteritis was unlikely given the baby was afebrile, and the duration of symptoms didn’t fit. If the US is unrevealing our plan was to then treat as GERD.
I hope to follow up with my preceptor on this case as it was a sad story, and I hope that baby is feeling better.

Fenstermacher, K., & Hudson, B. T. (2019). Practice guidelines for family nurse practitioners (5th ed.). Elsevier.
Maaks, D., Starr, N., Brady, M., Gaylord, N., Driessnack, M., & Duderstadt, K. (2019). Burns’ pediatric primary care (7th ed.). Elsevier.
2. Lindsay Trent posted Sep 8, 2022 5:44 PM
This past week, I experienced many chronic illness cases involving diabetes, hypertension, and hyperlipidemia. However, there was one patient who came in with a more unique case. This patient was a 40-year-old Hispanic female who presented with weight gain, hair loss, fatigue, dry skin, increased moodiness, difficulty concentrating, and significant brain fog for the past 3 months. She had a history of depression and was recently prescribed Wellbutrin. Upon initially starting the Wellbutrin, she noted the brain fog became worse; she noted she would enter a room and forget what she was in there for, leave the room only to remember why she had gone in, and then re-enter only to forget again. She discontinued the Wellbutrin and noticed a slight improvement but stated she was still having issues such as leaving her keys in her front door overnight. She recently traveled to the Dominican Republic to visit her mother, whom she found out had a history of hypothyroidism; the patient was wondering if this was potentially the cause of her problems as well. She had no history of abnormal TSH levels. While weight gain, hair loss, dry skin, and fatigue may be attributed to hypothyroidism, it does not explain the moodiness and brain fog. I worked with my preceptor and utilized UpToDate to find another potential differential that would explain these symptoms. We identified early menopause as another potential differential, as sleep disturbance, mood changes, and trouble concentrating as well as the other physical manifestations can all be attributed to perimenopause (Casper, 2022; Johns Hopkins, 2021). After we came to this conclusion, we put in orders for TSH as well as FSH to determine the best course of action for this patient (MedLine Plus, 2020). We also got her set up with Elavil to see if any of her symptoms would resolve if her sleep disturbances were addressed.
Casper, R. (2022). Clinical manifestations and diagnosis of menopause. UpToDate. Retrieved 2022, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause
Johns Hopkins. (2021). Perimenopause. Johns Hopkins Medicine. Retrieved 2022, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/perimenopause
MedlinePlus. (2020). Follicle-stimulating hormone (FSH) levels test: Medlineplus medical test. MedlinePlus. Retrieved 2022, from https://medlineplus.gov/lab-tests/follicle-stimulating-hormone-fsh-levels-test/

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