Description
I need help completing this assignment. I have included the case study information below, and the assignment to be completed is attached. Please let me know if you have any questions, thank you!
Case Study
A 2-year-old black male, with a past medical history significant for sickle cell anemia (Hb SS) and hemophilia B, presented as a transport to the pediatric intensive care unit (PICU) from an outlying hospital secondary to altered mental status. Symptoms of lethargy and decreased activity began approximately 1 day prior to admission. The mother reported difficulty in arousing the patient on the day of admission. The patient also began to have symptoms of nausea and vomiting on the day of admission. Review of symptoms was negative for fever, chills, trauma, injury, and recent ingestions or medications.
Past medical history: Hb SS, hemophilia B, history of hemarthrosis, previously treated with factor IX
Family history: Brother and maternal grandfather with hemophilia
A CT scan of the brain was done following initial presentation. The scan revealed a left frontal intraparenchymal and a left temporal hemorrhage, with a 1-cm right shift. There was also effacement of the left lateral ventricle and the third ventricle. Patient was intubated and transported to the PICU for further care.
Evaluation
Physical Examination
General appearance: Patient intubated and sedated
Vital signs: T 99.8°F, HR 191, respiratory rate 18, BP 90/61 mm Hg
HEENT: Head normocephalic and atraumatic; pupils equal and reactive to light at 3 mm in size bilaterally, no icterus; endotracheal tube in place
Cardiac: Regular rate and rhythm, 2/6 systolic ejection murmur
Respiratory: Upper airway sounds transmitted throughout, good bilateral breath sounds
Abdomen: Soft, nontender, nondistended, active bowel sounds; without hepatosplenomegaly
Extremities: No clubbing, cyanosis, or edema. Good peripheral pulses. Capillary refill 2-3 seconds. No rashes noted.
Neurologic: Spontaneous eye movement. Moving all extremities in a purposeful manner. Glasgow coma score 7.
Initial Laboratory Analyses
CBC with differential: Hemoglobin 8.5 g/L, hematocrit 25%, platelets 143,000; total white blood count 16,800 with 92% granulocytes, 0% bands, 4% lymphocytes
Metabolic profile: Within normal limits
Arterial blood gas: pH 7.39, pCO2 35, pO2 61, HCO3 21
Coagulation panel: PT 13.6, PTT 35, INR 1, fibrinogen 540
Radiologic Evaluation
Figure 1.
CT scan of the brain showing left frontal temporal hemorrhage.
Figure 2.
CT scan of the brain showing left frontal temporal hemorrhage.
Diagnosis: A spontaneous intracranial hemorrhage secondary to hemophilia
Hospital Course
Hematology/Oncology and Neurosurgery services were consulted immediately. A central line was placed without complications. The patient was treated with factor IX 80 units/kg once, then received 40 units/kg every 12 hours. He was also transfused with 1 unit of packed red blood cells. His PT and PTT were monitored every 12 hours.
Neurosurgical recommendations included correcting the patient's factor level prior to any surgical intervention and treatment with decadron, to decrease cerebral edema. Intracranial pressure was managed by keeping the head of the patient's bed elevated at 30°, with the head midline. He was kept mildly hypothermic; ventilation and oxygenation were maintained through mechanical ventilation. Sedation and analgesia were achieved with continuous infusions of midazolam and fentanyl.
A repeat CT scan was done the following day; no significant change from the previous scan was seen. A transcranial Doppler scan was done to rule out vasculopathy related to Hb SS. The Doppler evaluation was within normal limits. This confirmed that the spontaneous hemorrhage was secondary to hemophilia, rather than to Hb SS.
On hospital day 2, the patient was taken to the operating room where
a craniotomy was performed, with evacuation of the intracranial hemorrhage in the left frontal temporal area. Approximately 40 cc of blood was evacuated.
On postoperative day 1, the patient developed bilateral pleural effusions, with bilateral lower lobe atelectasis/pneumonia. In light of his Hb SS disease, imaging was consistent with acute chest syndrome. The patient was treated with an exchange transfusion. On postoperative day 2, he was extubated without difficulty.
The patient was subsequently transferred to the pediatric ward in stable condition. He was treated for pneumonia with clindamycin and vancomycin for 10 days. While in the hospital, he received physical therapy. Prior to discharge, the patient had resumed normal activity and speech. As an outpatient, he continued to receive prophylaxis with factor IX twice a week.
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Explanation & Answer
Attached.
PATIENT CARE WORKSHEET
(INFANT, CHILD ADOLESCENT)
Student:
Date of Care: 10/24/2024
Name of the person giving the history (the
informant) Mother
Informant’s relationship to this child Parent
Patient Initial J.S
Admission Date: 2/24/2024
Date of Birth: October 24, 2022
Age: 2 years Height: 87 cm Wt(kg): 13 kg
Unit /Room: Pediatric ICU
Sex: Male
Allergies None documented
Race/Ethnicity Black/African American
Religion Not documented
Language English
Gender Identity
Male Female Both Neither
General Survey
While taking the history, perform a general survey
of the patient for the following:
ASSESS level of consciousness and mental status.
Findings
OBSERVE facial expression
NOTICE speech and articulation.
NOTICE comprehension of verbal communication
NOTICE ability to see, hear, and speak.
ASSESS mood or affect
NOTICE personal hygiene and dress.
OBSERVE skin color
OBSERVE posture or position
No facial expression observed, patient is sedated
Intubated, unable to speak
Not assessable due to sedation
Eyes closed but pupil reaction normal
Not assessable (sedated)
Hospital gown, hygiene maintained by care team
Normal
Supine, head elevated 30 degrees as per
neurosurgery recommendation
Intubated, sedated, no independent mobility
Mechanical ventilation with good bilateral breath
sounds
OBSERVE mobility and balance.
NOTICE the patient’s breathing effort
Sedated, Glasgow Coma Score of 7
REASON FOR SEEKING HEALTH CARE (Presenting Problem)
secondary to hemophilia, with altered mental status, lethargy, nausea, and vomiting.
HISTORY OF PRESENT ILLNESS: Symptom Analysis of Presenting Problem (Onset, Location, Duration,
Characteristics, Aggravating factors, Related symptoms, Treatment, Severity
Onset: Symptoms began 1 day before admission with lethargy, altered mental status, and vomiting.
Location: Intracranial hemorrhage (left frontal temporal area)
Duration: Ongoing
Characteristics: Decreased activity, lethargy, difficulty in arousing
Aggravating factors: Unknown
Related symptoms: Nausea, vomiting
Treatment: Hemophilia factor IX replacement, mechanical ventilation, sedation, surgery (craniotomy)
Severity: Severe, with intracranial hemorrhage, requiring PICU care
PRESENT HEALTH STATUS
• Describe the child’s current health conditions.
Sickle cell anemia, hemophilia B, acute intracranial hemorrhage.
ο How long has the child had these conditions?
Since birth (congenital conditions)
ο How have these health conditions affected the child’s daily activities?
Likely frequent hospitalizations and medical treatments due to hemophilia and sickle cell disease.
What medications or supplements does the child take? (Include prescriptions, over-the-counter, and
herbal supple-ments. Document if none are taken.)
Name of
Drug/Supplement
Factor IX
Midazolam
Fentanyl
Red blood cell
transfusion
Dosage/Frequency
Last Dose Taken
Reason for Taking
80 units/kg once, then
40 units/kg q12h
Continuous infusion
Continuous infusion
1 unit
PICU treatment
Hemophilia B
PICU treatment
Sedation
Pain control
To correct anemia
PICU treatment
During
hospitalization
Describe any allergies to medications, foods, medical products (e.g., latex, contrast, tape), or things in
the environ-ment. Describe the symptoms and their frequency. (Document if there are no allergies.)
Allergic to
No known drug allergies.
History
Prenatal care
Maternal health
during pregnancy
Findings
Considerations
Where care occurred,
gestation at first
prenatal visit, total
number of visits
General maternal
health/ disease states
before and during
Bachelor of Science in Prelicensure Nursing
Angeles College
Findings
Not provided
Unknown
May 2023
Substance use
during pregnancy
Mother’s
emotional state
during pregnancy
Labor and delivery
process
Mother’s labor
Infant delivery
Newborn Course
Birth history
Apgar score
Neonatal
complications
Hospitalization
stay
pregnancy
Complications
associated with
pregnancy (bleeding
problems,
hypertension, edema,
proteinuria, unusual
weight gain,
infections, gestational
diabetes, preterm
labor)
Alcohol; tobacco;
medications; street
drugs (include type,
dose, duration, and
month of gestation
when used)
Anxiety, depression,
acceptance of
pregnancy, mental
health issues
Place of birth
(hospital, home, birth
center)
Spontaneous,
induced, duration,
medications,
complications
Vaginal, cesarean
section, use of
anesthesia, special
equipment and
procedures
Gestational age and
growth pattern
Apgar score and type
of resuscitation if
required
Respiratory,
infections, feeding,
hyperbilirubinemia,
congenital
abnormalities
Duration in hospital,
any follow-up care
after discharge,
laboratory results
Bachelor of Science in Prelicensure Nursing
Angeles College
Unknown
Unknown
Not provided
None
None
Unknown
Unknown
Likely undiagnosed sickle cell disease and
hemophilia at birth
To be filled
May 2023
(bilirubin, newborn
screening) Was
newborn discharged
with mother?
Immunization
(Hepatitis B)
Childhood Illnesses (Check all that apply)
Measles
Mumps
Pertussis
Influenza
Rubella
Chickenpox
Otitis Media
Streptococcal
Throat
Other
Description
Date/Year
Residual Problems
Previous medical
conditions
Previous
hospita...
