Breast No masses lumps deformities or discharge Genitourinary Assessment of

Breast no masses lumps deformities or discharge

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Breast:No masses, lumps, deformities, or discharge. Genitourinary:Assessment of genitalia deferred. Musculoskeletal: No limb deformities. Move all extremities spontaneously, but weakly. No evident focal deficits. Macular discoloration at wrists. No localized musculoskeletal pain. Neurological:Patient has decreased level of consciousness. Behavioral/Psychiatric: No behavioral disturbances. Affect appropriate.
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Pediatric SOAP NotePediatric/Adolescent Assessment Tools: Vital signs assessment tool: tachycardic, tachypneic, hypotensiveAges and stages if child is able to cooperate and comprehend questions (Chiocca, 2015)Carey temperament Scales (parent - reported): to determine if child copes effectively (Chiocca, 2015) May not be appropriate for this case study given the child’s current situation.Present Developmental:Erickson’s stage 2: Autonomy vs Shame – This child is dealing developing a sense of personal control over physical skills. If children are not encouraged in this stage the begin to feel inadequate (Chiocca, 2015). Given this child’s current situation and the complication of down syndrome, it is difficult to assess this stage.Lab and/or Diagnostic Tests: CBC – elevated white count, decreased platelet count, CMP – multiple electrolyte abnormalities, Lipase - elevated, Lactic acid - elevated, VBG - acidotic, PT/INR - elevated, UA – dark but otherwise unremarkable, Amylase - elevated, CT abdomen/pelvis – duodenal hematoma, skeletal survey – acute, healing, and old rib fractures, head CT - normalDIAGNOSISDifferentials:1.Traumatic brain injury (S06.2X9D) As evidence by decreased level of consciousness and other signs of trauma. TBI is a must not miss diagnosis (Chiocca, 2015). 2.Child Abuse (T76.12XA) As evidence by blunt trauma and skeletal survey that shows fractures at different stages of healing. (Chiocca, 2015). 3.Sepsis (A41.9). As evidenced by lethargy, tachycardia, tachypnea, and abnormal lab values. Final/Primary Diagnosis: Child Abuse, blunt abdominal trauma, and SIRS (S86.111A) This child has multiple appropriate diagnoses as he is dealing with the health effects of apparent child abuse. PLAN:1.Plan: Initial management is to stabilize the patient. Patient will need continuous cardiac and pulse oximetry monitoring. He needs supplemental oxygen therapy (titrate to O2 saturation greater than 92%). Two large bore IVs are needed for rehydration. Once completed patient can be reassessed for needs. Child protective services will need to be contacted in a timely fashion and there may be a need for hospital security (Chiocca, 2015). Get social worker involved to handle the nonclinical portion of this case.
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