Patrick O’Donnell is a 22-month-old boy of Irish-American descent. His mother has concerns about loose stools for the past 3- to 4-months. His stools have gradually become looser and more frequent, and he has been “irritable” lately. His mother says he is active and sleeps well. She describes him as a “picky eater.” Patrick lives with both parents and a four-year-old sister, who is healthy. Because both parents work full-time, Patrick and his sister go to their grandmother’s home Monday through Friday for daycare. His mom had not been particularly concerned about his crabbiness or picky eating until his Grandma mentioned that Patrick has been taking longer naps and she wonders how he'll ever get potty trained, because of his loose stools.

Objective
See Growth Chart
• Vital signs: weight (10.8 kg/23 lb. 13 oz.), length (84 cm/33.25”), and temperature (97.6 ax). See growth chart.

Some of Patrick's physical exam findings are as follows:
• General: Patrick is a thin, somewhat pale toddler, sitting quietly on his mother’s lap.
• Cardiac: Cardiac exam is normal (no murmurs, cyanosis, or clubbing).
• GI: His GI exam reveals a slightly distended abdomen, active bowel sounds, some tympany, non¬tender to palpation, without masses or hepatosplenomegaly.
• Skin: His skin is pale, with no rashes or lesions.

You order some lab work:
• CBC: All WNL for age except Hgb is 10.0 g/dL: (ref: 11.0 to ¬14.0 g/dL)
• tTG (Tissue Transglutaminase): 14.6 u/ml (ref: 10.0 is positive)

Assessment and Plan
Putting it all together:
1. Identify and discuss/analyze the most important aspects of Patrick's listed history ("red flags" in the subjective findings). What items are missing from Patrick's history?
2. Identify and discuss/analyze the most important objective findings. What data is missing from a complete exam for this patient?
3. State your assessment: List differential diagnoses for this patient (pretend you don't know the given lab results).
4. Clearly state both a short-term and long-term plan for Patrick. Include diagnostic testing, consults, referrals, patient education, follow-up. Discuss the rationale for the measures contained in your plan, using peer reviewed, evidence based, and primary academic references to support your rationale.