Laura Katherine Castano Barragan

Journal 6

Date: 7/29/2020

Professor El Kholy, Amira

I-Human, 6-month wellness visit, 93%

I started the scenario in I-Human, K.S, 6-month-old male brought by his mother and

grandmother for his 6-month wellness visit. I achieved a score of 93%. Pt was born at 39 weeks,

Normal spontaneous vaginal delivery (NSVD), no complications. Baby was circumcised at day

two and they were discharged home from the hospital. Mother is 17 y/old. Lives with her mother

in an apartment. They receive supplemental security income (SSI) and help from Women’s,

infants and children (WIC) program. Father is not involved in care. No relevant family illnesses

No hx of hospitalizations, or injuries. Pt meet all the milestones according to age. Anterior

fontanelle open, posterior fontanelle closed, positive Babinski and plantar grasp reflex. Moro,

palmar grasp, stepping and sucking reflexes are negative. Normal lung sounds, no use of

accessory muscles, normoactive bowel sounds, change of diaper done 4 times a day. Red and

shiny rash on buttocks, thighs, stomach and waist area in the last two days. Circumcision is

healed, no signs of infection. Needs next dose of immunizations. I recommended to teach about

treatment and prevention of diaper rash and to give immunizations due for 6-month pt: 3rd dose

of Hep b, 3rd dose of rotavirus, 3rd dose dtap (diphtheria, tetanus and acellular pertussis) , 3rd dose

pneumococcal conjugate, 3rd dose of inactivated poliovirus, Annual dose of influenza

 I was able to perform a head to toe assessment on the baby and to ask his mother

questions about his history and recent rash. During the history the mother said that she changed

the baby 4 times a day. One of the reasons for diaper dermatitis in infrequent change of diaper

that allows the patient to be wet for longer periods of time. This case was a good review on how

to do head to toe assessment and the schedule for vaccination in pediatric patients. My strength

in this scenario was the recommendations made for the patients which coincided with the

expert’s suggestions.