Cardiovascular History of congenital heart problems. Does not have any issues now. Skin Denies any skin issues except for diaper rash Respiratory Child has been breathing fast. Denies shortness of breath, wheezing or coughing. Eyes Denies any problem in eyes. Gastrointestinal Abdominal pain is the chief complaint. He has not been eating well. Also, he has diminished output. Ear Denies any problem in ears Genitourinary/Gynecological Diminished urinary frequency. Pee is dark and has strong smell. Nose/Mouth/throat Denies any problem in nose, mouth or throat. Musculoskeletal Negative for seizures, syncope, tingling,
paresthesia or numbness. Breast Deferred Neurological Denies seizures, syncope, black out spells, parenthesis, tingling or numbness. Heme/Lyme/Endo Denies night sweats, bruising, increased thirst, heat or cold intolerance. Psychiatric He is normally happy and playful, but is not happy currently. OBJECTIVE Weight 22 lb, Temp 97.9 C oral BP 68/48 Systolic BP 68/48 Height 2’4” Pulse 80, regular Resp 50 bpm HR 160 BPM General Appearance and parent-child interaction Child looks weak and lethargic. Small for age. Down syndrome features Skin Skin is cool, sweaty and slightly mottled. Diffuse diaper rash. Faint circumferential macular discoloration at wrists consistent with aging ligature marks HEENT Head: Normocephalic. Features are all symmetrical. Hair is thick and evenly distributed. No visible scaliness, edema, masses or lumps noted. Non-tender. No signs of trauma. Flat face, upslanting eyes. Eyes: PERRLA. Iris is normal. no discharge noted. No conjunctival pallor, No scleral icterus Ear: Canals are patent. Normal appearing external structures. No deformities noted. No discharge noted. Nose: Nares are symmetrical. Nasal mucosa without inflammation. No septal deviation. Throat: oral mucosa noted moist and pink. No hoarseness; clear mucosa. Tonsils without exudate. Normal gag reflex. Dental caries noted. Cardiovascular Tachycardia noted. S1 and S2 with normal rate and rhythm. 3/6 systolic murmur noted. Respiratory Respirations are regular and unlabored with symmetric chest wall. Lungs are clear to auscultation for all respiratory locations. No adventitious sound noted. Gastrointestinal Diffuse abdominal tenderness, guarding and rebound tenderness. Fading ligature marks. Abdominal distension, epigastric bruising noted. Reducible 2.0 cm umbilical hernia.
Breast Deferred Genitourinary Bladder is non-distended. No suprapubic pain observed. Musculoskeletal Spine is straight with no kyphosis or scoliosis. No lesion. No joint deformities noted. No ROM observed. Neurological Normal bulk. No rigidity. No signs of trauma Psychiatric Decreased level of responsiveness. Lab test Tests are based on the basis of differential diagnosis: blunt abdominal trauma amylase, serum lipase PT/INR lactic acid, serum venous blood gases (VBG) comprehensive metabolic panel (CMP) complete blood count (CBC) CT abdomen/pelvis with IV contrast volvulus (NOS) CT abdomen/pelvis with IV contrast PT/INR complete blood count (CBC) lactic acid, serum comprehensive metabolic panel (CMP)
You've reached the end of your free preview.
Want to read all 10 pages?
- Summer '17
- Bowel obstruction, Systemic inflammatory response syndrome, NSG6435 Week 7 Discussion