Clinical Assignment Mindmap by

Patient Data

basadjulia1_2 — 2020-11-27 10:20:17 UTC

J. K. Female
DOB: 12/13/2007 - 12 years old
Allergies: NKA
Weight: 75.0kg

- Post-op complications related to appendectomy 2 weeks prior - pt came in with fever and upper abdominal pain and reported being unable to walk unless completely hunched over
- Query abdominal abscess
- Possible drain insertion
- Not eating well

TFI: 115ml/hr --> 2760ml/day

Family/Psychosocial

basadjulia1_2 — 2020-11-27 10:26:20 UTC

- mother at bedside from 4am-10am, leaves for work during the day
- stepfather working abroad
- younger sibling (10) at home
- older sibling (18) lives with boyfriend
- vocalized siblings "don't really care" about stay in hospital

- biological father passed away 4 years ago
- uncle died by suicide
- limited support network

Strengths

basadjulia1_2 — 2020-11-27 10:28:48 UTC

- Pt is talkative and able to communicate efficiently and express needs
- Pt listens
- Pt is independent with activities of daily living
- Pt is positive and keen on getting back to school and seeing pets at home
- Mother is supportive

Neuro

basadjulia1_2 — 2020-11-27 10:29:16 UTC

- A & O x 3

Respiratory - normal

basadjulia1_2 — 2020-11-27 10:30:04 UTC

- Clear lung sounds
- RR: 16

Genitourinary

basadjulia1_2 — 2020-11-27 10:34:03 UTC

- Voiding clear yellow urine about 3x a day as reported by pt
- Pt drinking about 150ml with each meal

Gastrointestinal

basadjulia1_2 — 2020-11-27 10:37:54 UTC

- DAT - pt is not eating hospital meals <25%
- Bowel sounds active, abd soft
- Pt reported regular brown colour of stool - LBM this AM
- Pt reports pain in

Pain

basadjulia1_2 — 2020-11-27 10:39:24 UTC

- 2/10 at rest using numerical scale
- 4-5/10 with movement
- dull ache, not radiating
using numerical scale
- non-verbals: grimace and clutching stomach when getting back into bed

IV

basadjulia1_2 — 2020-11-27 10:40:08 UTC

- D51/2 saline KCl 50ml/hr

Integumentary

basadjulia1_2 — 2020-11-27 10:49:08 UTC

- 3 healing incisions from lap appendectomy: no signs or symptoms of infection to the sites
- Skin warm to touch - Temp: 37.2
- Pt c/o "burning" sensation to IV site

Labs - all normal

basadjulia1_2 — 2020-11-27 11:03:47 UTC

Na: 136
K: 3.7
Cl: 103

WBC: 8.8
Neutrophils: 6.6
Lymphocytes: 1.5
Monocytes: 0.5
Eosinophils: 0.2
Basophils: 0.1

Medication

basadjulia1_2 — 2020-11-27 11:04:55 UTC

Scheduled:
- piperacillin-tazobactam in 5% dextrose, 3375mg q6h

PRN:
- morphine 2.5mg-5mg IV or tab q4h
- ondansetron 4mg IV
- Tylenol 325mg-650mg PO q4h
- Advil 400mg q6h

Cardiovascular - normal

basadjulia1_2 — 2020-11-27 11:24:36 UTC

- HR: 84
- BP: 101/64
- Strong radial pulses
- Cap refill: <2 seconds