The Family Nurse Practitioner

Medications:Currently taking no prescription, herbal, or over‐the‐counter medications.

Allergies:No known allergies to food, medications, or environment.

Vital signs:Weight in the office today is 3360 g; length: 48 cm; temperature: 37.2°C (rectal); pulse oximeter reading: 95% on room air.

General:Alert, active baby.

Skin:Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; skin turgor intact.

Head:Molding present; anterior fontanel open and flat (2 cm × 2 cm); posterior fontanel open and flat (1 cm × 1 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 patent; no discharge; mild nasal flaring.

Oropharynx:Mucous membranes moist; no teeth present; no lesions.

Neck:Supple; no nodes.

Respiratory:RR = 68; crackles present in lower lung fields bilaterally; mild intercostal retractions; 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. Umbilical cord is in place with no signs and symptoms of infection.

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, gag, plantar, palmar, and Babinski reflexes.

1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Chest radiograph___Arterial blood gas (ABG)___Pulmonary function tests

2 What is the most likely differential diagnosis and why?___Transient tachypnea of the newborn___Pneumonia___Neonatal sepsis

3 What is the plan of treatment, referral, and follow‐up care?

4 Are there any demographic characteristics that would affect this case?

5 What if the patient lived in a rural, isolated setting?

6 Are there any standardized guidelines that should be used to assess or treat this case?

By Mikki Meadows‐Oliver, PhD, RN, FAAN

Siobhan is a 4‐day‐old infant in the office with her mother for an initial visit and weight check. Her mother states that Siobhan has a rash on her chest and arms that has been intermittent for the past 2 days. There do not seem to be any triggers for the rash. Siobhan’s mother has washed all of the baby’s clothes in a hypoallergenic cleanser only and has not used any moisturizers on the skin since the baby was discharged from the hospital. The rash also appears when Siobhan is clad in only a diaper. The rash does not appear to cause discomfort for Siobhan. Siobhan’s mother has not found anything that makes the rash better or worse.

Birth history:Siobhan is the product of a 40‐week gestation. Her birth weight was 3600 g. Further questioning about Siobhan’s birth history reveals that the mother’s pregnancy was normal. She had no infections, falls, or known exposures to environmental hazards. She did not use alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. During labor, Siobhan’s mother received a narcotic analgesic 1 hour prior to birth. Siobhan was delivered via spontaneous vaginal delivery and her Apgar scores were 7 at 1 minute and 9 at 5 minutes.

Social history:Siobhan was born to a single, 18‐year‐old mother. Siobhan’s father is involved but does not reside in the household. Siobhan lives in a 2‐bedroom apartment with her mother and maternal grandmother (MGM). The MGM is able to help Siobhan’s mother provide care. Siobhan’s mother receives several governmental subsidies such as the Women, Infants, and Children (WIC) Supplemental Nutrition Program, Temporary Assistance for Needy Families (TANF), and Medicaid. Educationally, Siobhan’s mother is completing coursework for her high school diploma. Siobhan’s father is also a high school student. There are no smokers in the home. The family has a dog.

Diet:Siobhan is being fed a milk‐based formula—2 oz every 3–4 hours.

Elimination:6–8 wet diapers daily with 3–4 yellow, seedy bowel movements.

Sleep:Sleeps between feedings.

Family medical history:PGF (age 40): asthma; PGM (age 38): obesity, high cholesterol, hypertension; MGF (age 36): sickle cell trait; MGM (age 34): bipolar disorder; mother (age 18): sickle cell trait; father (age 17): eczema.

Medications:Currently taking no prescription, herbal, or over‐the‐counter medications.

Allergies:No known allergies to food, medications, or environment.

Vital signs:Weight: 3690 g; length: 44 cm; temperature: 36.8°C (rectal).

General:Alert, well‐nourished, well‐hydrated baby.

Skin:Scattered 1‐cm, yellow‐white papules on an erythematous base on the trunk, upper arms, and thighs; lesions are nontender to touch; lanugo over shoulders; no cyanosis of lips, nails, or skin; no diaphoresis noted; good skin turgor.

Head:Normocephalic; anterior fontanel open and flat (0.3 cm × 3 cm); posterior fontanel open and flat (0.5 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 patent; no discharge.

Oropharynx:Mucous membranes moist; no teeth present; no lesions.

Neck:Supple; no nodes.

Respiratory:RR = 28; clear in all lobes; no adventitious sounds noted; no retractions; 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. Umbilical cord is in place without signs and symptoms of infection.

Genitourinary:Normal male; testes descended bilaterally; circumcision healing well.

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.

1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Skin biopsy___Peripheral blood smear___Bacterial/viral culture from the lesion

2 What is the most likely differential diagnosis and why?___Milia___Erythema toxicum___Herpes simplex virus

3 What is the plan of treatment?

4 Does the patient’s psychosocial history impact how you might treat her?