Discussion paper12 Month Old Child Check Up with Stage 4 Tumor NeuroblastomaDiscuss the history that you would take on this child in preparation for the 12 month well-child visit. Include questions regarding her growth and development that are appropriate for her age.Describe the developmental tool to be used for this 12 month old child, its reliability and validity and how Asia scored developmentally on this tool.Is she developmentally appropriate for her age?What immunizations will she will be getting at this visit?What is the patient/family education/anticipatory guidance and follow-up will be receive?Hello Follow instruction please;Cite your sources in your work and provide references for the citations in APA format with at least 6 references, no older than 5 years old.Apply information from the Case Studyin the attachment to know the history of the patient below and to do the discussion. The patient has had the following check- up already 2 months old, 4 month old and 9 month old checkup and I would like you to complete the discussion for her 12 month old check-up visits.Below is part of the case study, you will find the remaining of the story in the case study.When Patient comes back to see you for her 12-month checkup, you read the consultant notes from the pediatric hematology-oncology specialist: She has a Tumor, that was confirmed to be Stage 4S and lower-risk: She did not have the MYC-N gene amplification and had favorable histology. The family and oncologist decided together that because the primary tumor was large, resection was a better option than observation for resolution. Of course, Asia will be observed closely for the next several years to make sure that the metastatic lesions resolve and that the primary tumor does not recurred
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This is The Case Study
Pediatrics Infant female has had the following well-child visits already (2 months old, 6 month old, and 9
Chief Complaint: Infant female well-child visits
Asia, a 2-month-old little girl who is brought to the clinic by her mother, Karen Foster, for a checkup and
shots. This is her first visit to this clinic.
1) Question: You ask Mrs. Foster how Asia has been doing.
Answer she replies that everything has been “going great.” Because this is the baby’s first visit, you
obtain a birth history:
2) Question: “Were there any complications or infections during your pregnancy? Did you take any
medications? Did you use any drugs or alcohol?”
3) Question: “I had no problems except for a urine infection at the beginning of the pregnancy. It
was treated with an antibiotic. Other than that, I didn’t use any medications and I didn’t drink
alcohol, and I never have used any drugs.”
4) Question: “Was your doctor concerned with any of your prenatal labs: HIV, RPR, Hepatitis B, or
Group B strep?”
Answer: “No, not that I can remember.”
You glance at Asia’s chart and confirm the following about her birth:
Delivery date: Two days past due date
Birth weight: 7 lbs., 11 oz. (3.48 kg)
No complications in the nursery.
Received hepatitis B vaccine (recorded in state immunization registry)
Discharged two days post birth.
5) Question “Do you remember them telling you at the hospital that Asia passed her hearing test?”
Answer: “Yes, she did. I remember because someone else I met in the hospital had a baby that did not
pass and they were deciding where the baby would go for definitive testing. They told her not to worry
too much because the nursery test was just a screening test and can have false results, and more
intensive testing was needed.”
Dr. Clark reminded you that social history and diet are very important in a child’s overall growth and
development, so you take a detailed history in these areas.
6) Question: “Who lives at home with Asia? Does she go to daycare?”
Answer: “Her dad, 2-year-old brother, and I live with her at home. She doesn’t go to daycare yet, but I’m
going back to work in a month, so I’ll have to put her in the nursery then.”
7) Question: “Is Asia breastfeeding or bottle-feeding?”
Answer: “I give her formula. She takes about 4 oz. every three to four hours. I mix one can of
concentrate with one can of water. She seems to be doing fine with it, but is there a particular formula
that you would recommend?”
FYI: (See below for information that would help you respond to mother’s concerns about formula.)
Breast milk is the preferred source of nutrition for most babies.
Commercial formulas provide complete nutrition for those babies whose mothers are unable or
unwilling to breastfeed. Available formulas include those made with:
Cow’s milk protein
Soy protein, or
Hydrolyzed cow’s milk protein
There are also specialized formulas that provide protein in the form of simple amino acids (the true
Preparing the Formula
Ready-to-feed formula: Baby is fed directly from the bottle
Powder: Two scoops of the powder are mixed with 4 oz. water
Formula concentrate: ratio is one part concentrate to one part water
There is no need to give an infant extra bottles containing water only, because formula or breast milk
fulfills maintenance fluid requirements.
Transition to Regular Cow’s Milk
Infants should take breast milk or formula until 12 months of age. According to the American Academy
Young infants cannot digest cow’s milk as completely or easily as they digest breast milk or formula.
Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s
Cow’s milk lacks iron, vitamin C, and other nutrients that infants need.
It can also irritate the lining of the stomach and intestine, leading to blood loss in the stool.
Cow’s milk does not contain the optimal types of fat for growing infants.
“How many diapers do you change in a day?”
“She wets about eight diapers a day. She has one or two greenish-brown stools every day.”
TWO-MONTH GROWTH CHART
Weight and length: 50th percentile
Head circumference: 75th percentile
Weight-for-length: 50th percentile
You determine that Asia’s growth is appropriate.
TWO-MONTH PHYSICAL EXAM
Asia does not cry when you place her on the table; in fact, she smiles at you immediately.
Your examination findings:
Heart rate: 100 beats/minute
Respiratory rate: 40 breaths/minute
General: Active, alert, and nontoxic appearing
Head, eyes, ears, nose and throat (HEENT): Anterior fontanelle is soft and flat. Red reflex is present
bilaterally; sclerae nonicteric. Mild neonatal acne is present. Lips are moist and pink. Tympanic
membranes clear bilaterally.
Lungs: Clear bilaterally, with equal air movement.
Heart: Regular rate and rhythm with no murmurs.
Abdomen: Normal bowel sounds, no masses; abdomen is soft, nontender, and nondistended.
Hips: Ortolani and Barlow maneuvers negative bilaterally.
Genitalia: Normal female genitalia.
Neurologic: Tone is normal. Moves all extremities equally. Moro reflex is present and symmetric. Toes
are up going bilaterally on Babinski maneuver.
Skin: There are no rashes, except for neonatal acne.
Back: No sacral dimple or hair tuft present.
Expected tasks for age
Asia’s physical exam so far is normal, so you proceed to the developmental screen.
Asia seems to recognize her parents and she smiles a lot.
Has also noticed that she can lift her head and chest off the bed, but cannot roll over yet.
Sometimes makes cooing noises at home.
Can lift her chest off the table with her head held up around 90 degrees.
Can follow past the midline.
Smiles often when you talk to her.
Asia’s development is appropriate for her age.
TWO-MONTH ANTICIPATORY GUIDANCE
At this point you reassure Asia’s mother that she has a very healthy baby, and you ask her if she has any
Mrs. Foster wonders when she should start giving Asia solid foods and whether she should give her
Some infants may be started on rice cereal with a spoon at age 4 months.
She also asks when she will sleep through the night:
Most babies sleep through the night by age 4 to 6 months.
To help prevent SIDS, an infant should continue to be placed on her back to go to sleep.
PLACEMENT OF CAR SEAT
Mrs. Foster tells you that she bought a new car seat for Asia and asks you where she should place it in
Answer: Until age 2 years, children should face rearward.
Asia today at her 2-month visit Received the appropriate immunizations for Asia today are her first
DTaP, Hib, IPV, PCV13, RotaV. HepB.
2 month old patient education about Vaccine Adverse Events and and follow-up
Common side effects of immunizations are “knots” in the skin at the injection site (which may persist for
a few weeks) or fussiness and fever for 24 hours. If these persist longer than 24 hours or there are more
serious side effects-such as seizures or inconsolability-the child should be evaluated right away. The risks
of adverse effects are far outweighed by the risks of serious consequences from contracting the diseases
themselves, so the AAP recommends routine immunization of all healthy children.
Dr. Clark returns and verifies the information you provided. After asking if Ms. Foster had any other
questions or concerns (she didn’t), you and Dr. Clark record the orders for the vaccines and then ask Ms.
Foster to schedule the next checkup, when Asia is 4 months old.
INTERIM HISTORY: AGE 6 TO 9 MONTHS OLD
Today is Asia’s 6-month birthday, and she is here for her well-child visit.
You review her chart and see that she had a 4-month well child visit with Dr. Clark. He did not have any
concerns about Asia. He administered all of the required vaccines and documented that he provided
After playing with Asia and getting a big smile from her, you get an interim history, as well as an updated
diet and developmental history, from her mother.
Doctor question: “How has Asia been doing since I last saw her? Has she been sick at all or has she been
in the hospital?”
Mother Answer: “She’s been doing great. Over the last couple of months, she has really become
interactive and playful. She’s a lot of fun.
Mother Answer: Health wise, she has had a couple of colds, because I had to put her in daycare when
she was 3 months old. But she hasn’t been sick enough to be in the hospital.”
Doctor question: “Is she still taking formula? How much? Have you been feeding her solid foods?”
Mother Answer: “She still takes formula, but now she takes about 8 oz. four times a day. I give her a
couple of ounces of water every day, too. She eats prepared baby food: fruits and vegetables and rice
cereal. I was thinking about starting her on some meats, but I’m not sure if she’s ready for them.”
You note this question and tell Asia’s mother that you will bring her a handout on feeding infants:
Doctor question: “Does she roll over or sit by herself? Is she talking?”
Mother Answer: “She’s been rolling over for a couple months, but she just started sitting by herself and
she babbles a lot, but she doesn’t say any words yet. She loves to laugh a lot.”
QUESTION REGARDING GROWTH TEACHING
Asia’s 6-month height and weight growth chart
You want to check Asia’s growth chart to make sure she has grown appropriately. You measure her head
circumference yourself and plot the following on the growth curve:
Weight: 7 kg (15.4 lbs.)
Length: 65 cm (25.6 inches)
Head circumference: 43 cm (17 inches)
SIX-MONTH PHYSICAL EXAM
You wash your hands and prepare for the physical exam. Before you approach Asia, you notice that she
is sitting on her mom’s lap with good head control and that she is very curious about her environment.
You take her from her mother and place her on the examination table. She cries initially, but you are
able to engage her by smiling and playing with her.
Asia is alert and active, often reaching for your stethoscope.
She is afebrile and her vital signs are normal.
Her entire physical exam, including her neurologic exam and red reflex, is normal. SIX-MONTH
Developmental Observations about Asia
Pulls to a seated position without a head lag.
Able to sit well without additional support.
Grabs block with her nearest hand and transfers it to the other hand and places it in her mouth.
Uses raking grasp to try to pick up a small toy on the table.
Frequently babbles, but not saying any specific words.
Asia performed the expected developmental milestones for a 6-month-old infant?
SIX-MONTH ANTICIPATORY GUIDANCE MANAGEMENT
After telling Mrs. Foster that Asia looks very healthy, you move on to anticipatory guidance. Even though
Asia is not crawling yet, now is the time for her parents to childproof the home:
TEACHING POINT at the 6-month Visit Toddler-Proofing the Home
There are several steps parents or guardians should take to childproof their home-even before the child
is crawling, much less already walking! These include:
Installing outlet covers
Putting in cabinet locks
Setting up stair barriers and
Making sure cleaning supplies and medicines are safely stored.
In addition, the number for poison control should be kept near the phone.
Car seat placement: The car seat should still be in the back seat, facing the rear.
Use of walkers: The AAP has recommended against the use of walkers because of the risk of injury,
especially when there are stairs in the home. In addition, walkers do not teach children to walk any
earlier than they otherwise would.
Dietary changes: New foods may be added to the diet every 5 to 7 days.
Developmental changes: 6-month-olds may be resistant to being away from their primary caretaker for
the next few months, but this “stranger anxiety” is normal.
If not already begun, now is a great time to start reading books to the infant.
Sleep patterns: The 6-month-old should be expected to take two naps per day, and will probably sleep
through the night.
SIX-MONTH VACCINES MANAGEMENT
Reviewing Asia’s immunization record, you confirm that she received her 4-month immunizations at that
well visit. You ask her mother if she has had any difficulties with her previous immunizations. She
reports some fussiness for a few hours, but she denies fever or other problems. You caution Ms. Foster
about using acetaminophen at the time of immunizations:
You decide to review the current year’s immunization requirements and recommendations.
Mrs. Foster asks you which immunizations will be given today:
You opt to hold the third IPV until the 9-month visit; the parent has been 100% adherent with office
visits, and this will reduce the number of injections for this visit to four (there is flexibility for the third
polio injection; it needs to be given anytime between 6 months and 18 months).
You and Dr. Clark bring the visit to a close by asking Mrs. Foster if she has any other concerns or
questions. She does not, and you ask to see her back when Asia is 9 months old for another well-child
Acetaminophen and Vaccines
Use of acetaminophen may cause a lower antibody response for some immunizations. It should be
administered only if absolutely necessary.
INTERIM HISTORY: AGE 6 TO 9 MONTHS OLD
Asia at 9 months, with her mother
It is now three months later, and Asia has come to the office for her 9-month health maintenance visit.
You enter the exam room to find Asia smiling and playful in her mother’s lap. She looks healthy and
appears to have grown well since her last visit. You sit down to take an interim history from her mother.
Doctors Question: “How has Asia been doing since I last saw her? Do you have any concerns?”
Mothers Answer: “She’s doing great. She’s just growing up so fast. I have no concerns.”
Doctors Question: “Is she still taking infant formula? What foods is she eating now? Is she having any
problems with diarrhea or constipation?”
Mothers Answer: “Yes, she’s still taking the same formula. She drinks at least three 8-ounce bottles a
day. She’s eating strained vegetables and fruits as well as lots of finger foods like crackers and toast. We
gave her some chicken last week, and she seemed to like it. Her bowel movements are regular, usually
two a day.”
Because Asia is now drinking less than 32 ounces a day of vitamin-enriched formula, you recommend
Asia be supplemented with an over-the-counter infant liquid multivitamin.
Doctors Question: “Is she napping during the day? How is she sleeping at night?”
Mothers Answer: “She takes a morning and afternoon nap, and then she sleeps through the night.”
DEVELOPMENTAL MILESTONES TEACHING
Asia sits on the exam table.
Mrs. Foster seems to be very happy with how Asia has been doing. On this visit, the nurse has already
obtained Asia’s measurements and plotted her growth (shown above).
When you review the PEDS developmental screening form that Mrs. Foster completed, you note that
she has no concerns.
You now want to know if Asia has met her 9-month developmental milestones.
NINE-MONTH PHYSICAL EXAM PHYSICAL EXAM
Asia on the exam table
Asia seems to be right on track for her growth and development.
Asia’s mother has undressed her, and Asia lets you put her on the examining table.
You begin your exam in the least intrusive way, by auscultating her heart and lungs:
Chest/lungs: Symmetrical expansion, no retractions. Bilateral breath sounds are clear and symmetric.
Heart: Regular rate and rhythm, normal S1 and S2; no murmurs, gallops, or rubs.
Abnormal findings: Abdomen: Slightly distended. Active bowel sounds. A firm nodular mass is
palpable on the right side extending below the subcostal margin approximately 6 cm. Its diameter is
also about 6 cm and it does not appear to cross the midline. No splenomegaly.
NINE-MONTH PHYSICAL EXAM CONTINUED
You have discovered an abdominal mass and are very concerned as you complete your exam. Here is the
remainder of your findings:
Head, eyes, ears, nose and throat (HEENT):
Head: Anterior fontanelle 1 cm.
Eyes: No scleral icterus. Conjunctiva pallor noted. Extraocular movements are full; bilateral red reflex is
Ears: Tympanic membranes are gray with light reflex bilaterally. They are mobile on insufflation.
Nares: Patent, no discharge.
Oropharynx: Mucosa moist and slightly pale, pharynx nonerythematous.
Neck: Supple, no masses.
Lymph: No cervical, axillary, or inguinal adenopathy.
Skin: Normal turgor. No jaundice.
Abnormal finding: Pale nail beds.* Healing bruise on forehead. (Her mother tells you that she bumped
her head on the coffee table when she pulled herself to standing.) No other bruises and no petechiae
*In children with darker complexions, pallor is detected in the conjunctiva, nail beds, and mucous
Neurological: Alert and appropriate. Normal tone and symmetric movement of all extremities. Sitting
well and pulls herself to stand. Crawls on exam table.
GU: Normal female genitalia.
SUMMARY STATEMENT CLINICAL REASONING
You begin thinking of what could be causing an abdominal mass in an otherwise healthy and
Based on what you know about the patient so far, write a one- to three-sentence summary statement to
communicate your understanding of the patient to other providers.
Asia is an asymptomatic, thriving 9-month-old girl incidentally noted to have a RUQ mass and pallor on
routine well child care exam. She has no lymphadenopathy, splenomegaly, or jaundice.
The ideal summary statement concisely highlights the most pertinent features without omitting any
significant points. The summary statement above includes:
Epidemiology and risk factors: Asia is female, 9 months old, and thriving.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
Asymptomatic, otherwise well
An incidentally noted RUQ mass
differential diagnosis? Select all that apply.
F. Hepatic neoplasm
J. Wilms’ tumor
DISCUSSING EXAM FINDINGS CARE DISCUSSION
After finishing your exam, you tell Asia’s mother that you will discuss all that you have discussed with Dr.
Clark and will return with him.
Dr. Clark asks you, “After I confirm your physical exam, if I agree with what you have found, how do you
suggest we break this potentially terrible news to the family?”
Asia has a palpable mass on her flank and we will undertake imaging in order to elucidate the etiology.
Asia has a firm area on the side of her abdomen. While there are mild causes of this firmness, such as
constipation, we are concerned that this could be something more serious.
I am concerned Asia may have a tumor in her abdomen. Sometimes these tumors can grow rapidly, so it
is important that we evaluate the area as soon as possible.
Have you noticed that Asia has a firm area on her side? If so, how long has it been there?
DIAGNOSTIC EVALUATION TESTING
Dr. Clark confirms your physical exam findings… After discussing the plan with mother, lab work and
imaging are ordered. You follow up with Dr. Clark the next week and he says that a biopsy was also done
to characterize the tumor and identify any metabolic abnormalities.
You review the results of Asia’s tests:
CBC with differential:
10.0 cells x103/µL
10.0 cells x109/L
Associated reference ranges in conventional and SI units.
Urine vanillylm …
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