1.
2.
How can I help himtoday?
a.
Questions(to mother) - Yields 100%
He isn’t himself. He’s been whining and refusing to eat. I think he’s saying that his
tummy hurts. When I took a look at his tummy, it had
...
1.
2.
How can I help himtoday?
a.
Questions(to mother) - Yields 100%
He isn’t himself. He’s been whining and refusing to eat. I think he’s saying that his
tummy hurts. When I took a look at his tummy, it had a big bruise.
Does he have any other symptoms or concerns we should discuss?
a.
Yeah, he vomited once last night, and he just keeps rubbing his entire stomach.
He’s not his usual, cheerful self. He’s really low in energy and withdrawn. He pees
less - you know, I’m not changing so many wet diapers, and his pee is dark and
strong smelling. Um, oh, and you can see, he’s still kind of sweaty and clammy. He
seemed to be breathing fast – maybe he’s nervous.
3. When did his abdominal pain start?
a.
About 2 days ago.
4. What are the events surrounding the start of his abdominal pain?
a.
My boyfriend says my baby fell from the bed during a nap and the problems
started after that. I don’t really know what he hit when that happened, but all his
problems started: whining, being really lowenergy or withdrawn, not eating, and
peeing less. He even vomited once last night.
5. Does anything make the pain in his abdomen better or worse?
a.
6.
He seems to be worse when I touch him, or pick himup.
How many wet diapers does your child make per day?
a.
7.
Usually? I’m not always there to change them, but nowthere seems to be fewer. Also,
his pee smells strong and it looks dark.
How many stool diapers does your child have per day?
a.
Normally? He usually poops once a day. I haven’t changed one in at least a day now.
I’m a bit worried about that.
8. What childhood illnesses has he had?
a.
Other than all the fuss with his heart defect, he’s been a pretty healthy little guy. I
mean, he’s slow - but that's what you get with Down Syndrome. Everything’s
affected…his growth, he doesn’t really say many words yet, and he doesn’t pick new
things up very quickly. That can be kind of frustrating, you know.
9.
Are his immunizations up to date?
a.
Yeah, they are, except for the last ones.
10. Is he taking any prescription medications?
a.
11.
Uh…no. Not anymore. He used to take medication for his heart problems, but
since they fixed thathe doesn’t need them anymore.
Is he taking any over the counter or herbal medications?
a.
No, I don’t give himany of those things.
12. Has he had pain in his abdomen before?
a.
No, not like this. He has always eaten well and he’s never acted like this before. I
can tell you that for sure.
13. Has he had any trauma to his abdomen?
a.
Maybe. He fell out of bed - maybe that’s the cause.
14. Does he have any allergies?
a.
No, he doesn’t have allergies.
15. Has he had any significant traumatic injuries or accidents?
a. He’s a real clumsy little guy. Always falling down, tripping over things, bumping into
things and stuff. Doesn’t look where he’s going. I wouldn’t call that a huge, big
accident though. He’s never hadany broken bones.
16. How is his family and family life?
a.
17. What and when did he last drink?
a.
It’s just me and my three kids: my 6-month-old, my 5-year-old and my two year
old. The father of my two-year-old is out of the equation, and never has been with us.
Sometimes my boyfriend, who’sthe father of my 6-month-old, stays over. I'm a
cashier at a retail shop - I mean I only graduated from high school - and so I don't
make that much money and I can't afford daycare, so my neighbors really help me
out. Sometimes my boyfriend looks after them, but he doesn't really like
tobecause you know kids - they whine or cry at the same time it seems and he
gets really on edge about it.
I tried to give himsome water two hours ago. He won’t take anything.
18. Can you tell me about any current or past medical problems he has had?
a.
He was born with Down Syndrome and when he was a baby he had a problem with
his heart. Part of that was he also used to have CHF and took medications, but that
got better after his operation. He is a bit slower to learn things than some other
children. But he has the biggest heart, and he justloves everybody. And he's
otherwise healthy. Please help my baby!
19. Does he have diarrhea?
a.
No, I haven’t seen any.
20. Is there any blood in his stools or with his bowel movements?
a.
He hasn’t pooped in a while. So actually, I’mnot totally sure about that, but I don’t
think so.
21. How long does the pain in his abdomen last?
a.
It’s been going on since it started. I mean, I wouldn’t bring himhere if I thought it was
going away.
22. Tell me about the health of his grandparents, parents, and children.
a. I’ve got anemia. My oldest has asthma. His birth father? I knownothing about his
health. Don’t care to be honest.
23. Any previous medical, surgical, or dental procedures?
a. My son had surgery to close a hold in his heart. I think they call the surgery
“ASD”. I haven’t taken himto the dentist, though. I really should do that.
24. Does he bruise or bleed easily?
a. Yes, he seems to get bruises really easily. He’s also a clumsy little guy, tripping
over stuff all the time.
25. Does he have any skin problems?
a. No, uh, that is, he’s a baby you know so he can get some diaper rash, but I think
he’s fine.
26. Has he recently had an upper respiratory infection?
a. Not recently…but he always seems to be congested.
27. Has he had any seizures?
a. No, nothing like that. I think my boyfriend and neighbors would have told me that
for sure.
28. Were there any complications with his birth?
a. You mean besides his Down Syndrome? No, the birth itself wasokay, I guess.
29. Has he had any trauma to his head?
a. No. Well, I mean, I don’t truly know. He could have hit his head when he fell.
I’mreally worried, do you think he hit his head hard or something?
30. Is he exposed to secondhand smoke?
a. Well…uh…I guess so. I do smoke – and so does my boyfriend – but we try to keep it
away fromthe kids and we don’t smoke in the same room as them.
31. Have you noticed a sudden change of behavior or personality in him?
Physical Assessment - Yields 94%
Respiratory Rate 50, normal, unlabored
Blood Pressure on one arm
68/40, normal, hypotensive
Brachial pulse on both arms
160, normal rhythm, weak
Cognitive
Verbal
Inspect skin overall Skin cool, sweaty, andslightly mottled. Thoracotomy scar consistent
withhistory of AV-septal repair. Diffuse diaper rash. Faint
circumferential macular discolorations at wrists consistent with
aging ligature marks.
Capillary refill (fingers)
Less than 3 seconds
Capillary refill (toes)
4 seconds
Quinke’s Test
Blanching observed
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