Head CT - UnremarkableSkeletal Survey – Healing rib fx to rt 4thand 5th. Old rib fx to rt 9thand 10th. Acute rib fx to lt 8th. NG tube and foley both present, mild bowel distension.HEADSS Assessment (Burns et al., 2016): Home: Lives with mother and 2 siblings. Mother’s boyfriend occasionally stays over.Education: Mother cannot afford daycare. Patient stays at home and is watched by neighbors or mother’s boyfriend.Eating: Per mother, patient has had decreased PO intake. Typically, he finishes most meals.Activities: For fun, he plays with toys and siblings.Drugs: Per mother, he has never been exposed to drugs or alcohol. He is exposed to second hand smoke, as his mother and her boyfriend smoke in the home.Sexuality: N/A Suicide/Depression: N/A Safety: Per mother, he has never been hurt by anyone on purpose. Denies any guns or weapons in the home. He always sits inhis car seat with a seatbelt while in the car. M
Pediatric SOAP noteDiagnosis1.Blunt Abdominal Trauma (Y04.8)a.This type of trauma can cause symptoms similar to what Tommy was experiencing – circulatory and neurologic complications. CT is the gold standard to identify intra-abdominal injury (Lynch, Kilgar & Shibli, 2018). In the case, the CT of the abdomen reveals internal hematoma with bowel distention. This type of diagnosis is crucial, as this type of injury can account for 50% of child abuse fatalities. The abdominal area is also the location that most providers overlook and miss potentially fatal injuries (Saxena, 2017). It is likely this type of injury was caused by punching, and therefore, could cause severe and life-threatening damage. When assessing patients with this type of injury, it is also important to assess the spleen, as this is the most common organ that is injured with abdominal trauma (Lynch, Kilgar & Shibli, 2018). 2.Child Abuse (T74.12XA)a.While Tommy’s diagnosis is considered abdominal trauma, the story that was given by his mother is not consistent with the injury that he has. The skeletal scan revealed multiple healing rib fractures, and adding frequent ER visits for “clumsiness,” difficult home life (finances, live-in boyfriend) and his developmental delays – there is high suspicion for child abuse, and this NEEDS to be included as an additional diagnosis. It is said that children with Autism, like Tommy, are at an increased risk of abuse and also, may suffer from PTSD as a result of abuse. That is why this diagnosis is so important and notifying the proper authorities is necessary (Roberts, Koenen, Lyall, Robinson & Weisskopf, 2015).3.Systemic Inflammatory Response Syndrome (SIRS) (R65.10)a.There are 5 common findings associated with SIRS (sepsis). Our patient, Tommy meets 4 of those 5 criteria.
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- Summer '17
- tommy, diaper rash, abdominal trauma