Patient’s name: Lucas Adamson
Age: 1 year, 7-month-old male
Past medical history
Drug history
Alerts and QOFs• Patient is up to date with his immunizations
Seen by Dr. Mohammed Shahid (Clinical practitioner role) – 6 weeks ago
History: Recurrent sore throat- 4 episodes in last 6 months
On examination– erythematous tonsils with white spots
Management: treat as tonsillitis with pen v. safety netting and worsening advice given.
Seen by Ms. Lucy Henderson (Pediatric Nurse practitioner role) – 5 weeks ago
History: Mum Reports recurrent loose stools associated with weight loss for last 14 months after introducing solid foods at 6 months of age. Mum thinks child maybe allergic to a type of food but unsure what food it is. No red flags or anaphylaxis symptoms. Patient is up to date with his immunization.
On examination; normal vitals, does not look dehydrated Weight today: 9.5kg. Weight plotted on growth chart is between 0.4 and 2nd centile (Birth weight 3kg)
Plan: Mum to keep food diary to find possible allergy. Advised to get annual flu vaccine. Weight to be measured again in 4weeks’ time Worsening advice given.
You are Emily, the mother of Lucas. He is a 1 year and 7 months old (19 months old).
You were asked by the health care assistant to book this appointment. Lucas has been having diarrhoea for last 14 months and he is also losing weight. The nurse checked his weight 3 days and he is now 9.38kg and it is recorded in the red book. Has at least 3-4 episodes of loose stool per week. Stools are non-bloody. Symptoms has not changed since you last saw the GP 5 weeks ago
Say No to other symptoms asked.
You suspect he has some food allergy – you suspect this because you read it online.
Your sister’s son has a condition where he can’t eat a certain type of food. You are not sure about the name of the condition.
You feed him with normal cereals like corn flakes, coco pops and other meals like pastaetc. He has no issues eating. No nausea or vomiting, no rashes. SAY NO TO ANY OTHER SYMPTOMS ASKED
Social history: He lives at home with you and your husband
PBIND- he was born at term with no issues. He was born in the UK and had new born screening which was all negative. Up to date with his jabs, he is otherwise growing well but he is not putting on weight.
Idea: you suspect food allergy and you are awaiting an appointment.
Concerns; his constant weight loss.
Expectations: You would like the GP do something about your son’s symptoms or refer to a specialist.
If you are told he may have coeliac –ask if you can stop giving him feeds containing gluten.
History
Management
Note: Calprotectin testing is generally not recommended for children under the age of 5. This is because inflammatory bowel disease (IBD) is less common in this age group, and baseline faecal calprotectin levels are naturally higher, making the results more challenging to interpret. However, very early-onset IBD (VEO-IBD) can occur in children less than 5, so it is sensible to offer this to this particular child