Question

Questions:

1. Include examples of pertinent positive and pertinent negative data associated with each?.

2. Provide rationales for your examples?

Objective Data

• Merci was diagnosed with celiac disease at about 11 months of age. Approximately 4 months after she started on solid foods.
• She had a term birth at 39 4/7 weeks of gestation with an Apgar 9/10.
• She developed normally until she began to have gastrointestinal symptoms and refused feeding.
• Smaller stature
• Merci is 30months old
• Slim with a prominent distended belly
• Merci’s chest was auscultated
• Heart tone were regular and heart rate is 102
• No murmur, gallop, or heaves were noted.
• Lungs were clear in all fields anterior and posterior
• Visuable thin legs and buttock

Subjective Data

• The patient has Celiac Disease
• Mother concerns if the patient is gaining weight
• She enjoys playing put she gets tired easily, she is irritable, needs to rest after playing
• Her appetite is good only half of the time
• Painful belly gas everyday
• No bloody stool
• She wants to eat the same food what the family eats
• She often has stomach pain and sometimes vomits after eating bread
• She is night waking
• She is usually constipated but occasional diarrhea
• Four smelling stools
• Mother is concerning about type 1 diabetes because she has heard that celiac disease can cause dm 1

Order

• Symptoms are different from one celiac to another
• Lab studies were drawn to check for anemia and diabetes (CBC, Glucose)
• A 3 day stool fat collection was ordered.
• Controlling the disease is the most important help that we can give Merci.
• Mrs. Garcia was reminded that gluten is toxic to Merci’s bowel.
• It was suggested that the entire family help with Merci’s diet
• Foods that contain gluten were reviewed.
• Mrs. Garcia was referred to both a nutritionist and a gastroenterologist.

Answer 1

Pertinent positives, which are disease specific and can be learned by rote, are used to rule in a particular diagnosis.

Pertinent negatives, which require more analytical and creative thinking, are gleaned from the differential diagnosis and function to rule out other diagnostic possibilities.

Celiac Disease

Celiac disease is an autoimmune disorder caused by an intolerance to gluten. Gluten is the general name of the proteins fonnd in wheat , rye, and barley and other grains derived from them.

In kids with celiac dis, gluten damageds villi, the finger like projections in the small intestine responsible for absorbeing nutrients from food. The body can't absorb nutrients the body needs to grow.

Object Data

Merci was diagnosed with celiac disease at about 11months of age. Approximately 4months after she started on solid foods.

She had a term birth at 39.4/7 weeks of gestation. with an Apgar score 9/10

She developed normally unit she began to have gastrointestinal symptoms and refused feeding

Smaller stature

Slim with prominent distended belly  

Merci's chest was auscultated.

Heart tone were regular and heart rate is 102

No murmur, gallop, or heaves were noted

Visuable thin legs and buttock

Subjective Data

The patient has celiac disease

Mother concerns if the patient is gaining weight.

Her appetite is good only half of the time  

Painful belly gas everyday  

No bloody stool

She wants to eat the same food what the family eats.

She often has stomach pain and sometimes vomits after

Eating bread.