Oral mucosa pink and moist, with presence of smooth tongue. The pharynx is non-erythematous and without exudates. Teeth with dental caries. Cardiovascular S1, S2 with regular rate and rhythm and 3/6 systolic murmur. Delayed capillary refill. PMI nondisplaced. Respiratory Thorax atraumatic per gross inspection. No labored movement if chest wall; lungs clear bilateral on auscultation. Gastrointestinal Diffuse abdominal tenderness, guarding, and rebound tenderness. Reducible 2.0 cm umbilical hernia. Abdomen is distended with active bowel sounds in four quadrants, and a 10 centimeters oval abdominal bruise from a fall. No hepatosplenomegaly. Breast Genitourinary Bladder is non-distended; diffuse diaper rash. Normal circumcised male; testes descended and none tender. No evidence of inguinal herniation.
Musculoskeletal Faint circumferential macular discoloration noted at wrist during extremities examination consistent with aging ligature marks. No deformities or bony crepitus; moves all extremities spontaneously, no localized musculoskeletal pain to palpation of extremities. None tender to vertebral palpation. No overt back deformities. Neurological Unable to explore. R/L pupils with normal reactive. Psychiatric Patient was listless, lethargic, showed low energy and dressed appropriately for the weather in clean clothing. In-house Lab Tests – document tests (results or pending) CBC, CMP, PT (16.5 sec)/INR (2.0), lipase (60 unit/L), amylase (115 units/L), lactic acid (>4mmol), urinalysis (-), and venous blood gases. Special Tests: Head CT: WNL. Skeletal survey: Acute rib fracture (left 8th), healing rib fracture (right 4th and 5th), old rib fractures (right 9th and 10th). No free abdominal air, diffuse bowel distention, no evidence of pneumonia a source of infection. CT scan of abdomen with oral contrast evidence a large central area of edema inclusive of collections of blood. Marked bowel distention and findings consistent with duodenal hematoma. Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment) Diagnosis Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) Differential Diagnosis: Child Abuse: acts of commission : patient shows old circumferential marks on wrists and ankles that suggest trauma, and oval abdominal bruise (unusual location for a bruise from a fall). In addition, the skeletal survey shows acute rib fracture (left 8th), healing rib fractures (right 4th and 5th), and old rib fractures (right 9th and 10th). In addition, the patient is exposed to several factors considered as high risk for child abuse which include: child younger than four years old, Down syndrome with special needs, global developmental delay, parental stress, single parent, multiple children, social isolation, lack of social support, low income, no biological transient caregivers in the home, and tobacco use by primary caregiver (Adelgais, et al., 2014).
- Summer '17
- NSG6435 Discussions