Neurological Mother reports increased lethargy and “not his usual self.” Denies any known head injury or loss of consciousness. Heme/Lymph/Endo Mother reports some bruising on his abdomen. Denies any bleeding or swollen lymph nodes. Psychiatric Mother reports patient is “not his usual self.” OBJECTIVE *GROWTH CHART ATTACHED AT END* Weight 22 lbs Height 2’4” Pulse 160 BPM BP 68/40 Resp 50/min, O2 Sat: 93% Temp 97.9F General Appearance and parent ‐ child interaction: Patient appears to be lethargic and uncomfortable. Skin Skin is cool, sweaty and mottled. Thoracic scar noted. Diaper rash noted. Circumferential macular discolorations noted on the wrist with aged rope-like marks. HEENT: Head: No signs of trauma. Flat face and upslanting eyes consistent with down syndrome facies. Eyes: PERRLA, no pallor or scleral icterus Ears: Tympanic membranes pearly with light bilaterally. No fluid or discharge noted Nose: Patency noted bilaterally. No discharge, erythema or inflammation noted Throat: No tonsillar exudate or erythema noted. Oral mucosa pink and moist. Neck: No lymphadenopathy or thyromegaly noted. Trachea midline and mobile. No accessory respiratory muscle use noted. Cardiovascular Tachycardia noted with early systolic murmur (S3). BLE capillary refill is 4 seconds. BUE capillary refill is < 3 seconds. Respiratory Breath sounds clear throughout lungs bilaterally. Non-labored breathing noted. No shortness of breath noted. Gastrointestinal Abdominal ecchymosis found over the epigastrum area – oval in shape and approximately 10cm in length. Abdomen distended and firm. 2 cm umbilical hernia noted. Rebound tenderness and guarding noted on palpation. BS normoactive x4 quadrants. Breast Deferred at this time. Genitourinary No suprapubic pain with palpation. No CVA tenderness noted. Circumcised male with descended testes. Diaper rash noted.
Pediatric SOAP note Musculoskeletal No deformities present. Neurological Patient appears lethargic. DTR +2 in all extremities. Cranial exam deferred. Psychiatric Patient appears to be lethargic. Minimal interaction with mother and staff. In-house Lab Tests – document tests **abnormal results only listed** CBC – WBC: 19,000, HGB: 9, HCT: 27, Platelets: 80, Neutrophils: 81, Seg. Neutrophils: 77, Bands: 4 CMP – NA+: 150, K+: 6.0, Ca2+: 7.0, CO2: 12, Glu: 130, BUN: 45, Cr: 2.0, Albumin: 2.5, Protein: 4.5, ALP:25 Lipase - 60 Amylase - 115 Lactic Acid - > 4 VBG – pH: 7.2; PvO2: <65% PT/INR – PT: 16.5; INR: 2.0 UA – Dark amber, strong odor CT Abdomen Pelvis w/IV contrast – large central area of edema with collections of blood. Bowel distention. Findings consistent with duodenal hematoma.
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- Summer '17
- tommy, diaper rash, abdominal trauma