Pediatric Clinical Assignment by Rachel McPherson

Patient Information

rachelmcpherson16 — 2021-02-04 23:54:56 UTC

T.D
Male
10 years old
62 kg
RFA: Left proximal tibial osteomyelitis w/ soft subperiosteal abscess.
Hx: fell on Jan 7th at school playing soccer, over the past week had a fever and pain on and of with swelling to lower left leg. Came into emergency on Jan 17th unable to put pressure on his left leg.
Sx: incision and drainage of left tibial abscess on Jan 21/21

Family

rachelmcpherson16 — 2021-02-05 00:21:49 UTC

Mother (Kiranjit) stays at bedside constantly
Aunt provides emotional support to mother and patient and brings food
Dad works out of town, and is unable to visit as patient is only able to have two visiting passes
Only child

Strengths

rachelmcpherson16 — 2021-02-05 00:27:06 UTC

Patient has strong social supports while in hospital
Mom provides emotional support and is a strong advocate for patient
Patient talks with father on the phone regularly
Able to vocalize concerns & needs (i.e. pain)

Fever

rachelmcpherson16 — 2021-02-05 00:41:27 UTC

38.7 @1254
37.2 @1350 (after admin of antipyretic)

Antipyretic Medication

rachelmcpherson16 — 2021-02-05 00:42:54 UTC

650mg Acetaminophen PO Q4H PRN

Infection

rachelmcpherson16 — 2021-02-05 00:43:55 UTC

Osteomyelitis w/ MRSA infection in the blood

IV

rachelmcpherson16 — 2021-02-05 00:44:59 UTC

Located Left Forearm
NS @ 10cc/hr

Antibiotics

rachelmcpherson16 — 2021-02-05 00:54:40 UTC

750mg Vancomycin IV TID
To be d/c'd on Feb 3/21

Surgery

rachelmcpherson16 — 2021-02-05 00:56:20 UTC

Incision and drainage of left tibial abscess completed by Dr. R. Mehin on Jan 21/21

Integumentary/Surgical Incision

rachelmcpherson16 — 2021-02-05 00:58:20 UTC

Free of redness
No swelling
No drainage
11 staples present
Edges well approximated
Incision covered w/ 4X4 gauze as pt. does not want to look at

Diet

rachelmcpherson16 — 2021-02-05 01:00:31 UTC

Eats roughly half of food supplied by hospital
Rest of diet is obtained from food brought in by aunt
eating habits are at baseline as reported by mother

Pain

rachelmcpherson16 — 2021-02-05 01:03:49 UTC

patient currently is denying pain, but had been noted earlier in the day

Mobilization

rachelmcpherson16 — 2021-02-05 01:06:51 UTC

pt has not been mobilizing d/t pain. However, nursing staff has been encouraging pt. to walk around unit once every 2 hours

Respiratory

rachelmcpherson16 — 2021-02-05 01:06:57 UTC

pt. is experiences SOB while mobilizing as they have been unable to mobilize normally for 2 weeks now

Cardiovascular

rachelmcpherson16 — 2021-02-05 01:21:39 UTC

CWMS satisfactory to lower limbs

Neurovascular

rachelmcpherson16 — 2021-02-05 01:21:57 UTC

dorsalis pedis & posterior tibial pulse strong
normal nerve function
no pallor/paresis/paralysis/pain
CWMS within normal limits
Cap refill <2 seconds

Analgesic Medication

rachelmcpherson16 — 2021-02-05 01:48:47 UTC

650mg Acetaminophen PO Q4H PRN
1-2 mg Morphine IV Q2-3H PRN

Resources

rachelmcpherson16 — 2021-02-06 02:26:09 UTC

Aunt brings in supplies to patient and mother
Patient has strong friend and family support system

GI/GU

rachelmcpherson16 — 2021-02-06 02:28:54 UTC

Voiding normally