Question

Mary is a 12 month old who has been vomiting for the past 12 hours. Mary woke up at 5 AM but has not been able to “hold anything down”. Mary’s mother is concerned because it is now 4:00 pm. Mary’s mother calls the primary care office and is recommended by the nurse to have Mary evaluated at the clinic (Dr. Office). On initial assessment, Mary is lethargic and very quiet. She has mild nasal congestion and Her lips and skin are dry. She occasionally cries, but does not produce tears. Mary’s diaper has not been changed since 5 am and is currently dry upon this visitation to the clinic. Note: The season is late winter.

Mary lies very quietly on the examination table. Her vital signs are:

Temperature: 101.1^O F or 38.3 C

Apical Rate: 153 bpm

Respiratory Rate: 42 breaths per minute

Blood pressure 90/48

Birth weight: 8 lbs

Current weight: 21 lbs

Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz

A fluid bolus is ordered by the physician and after administration of the bolus; Mary perks up a little bit. The doctor then orders Tylenol for the patient.

Mary’s laboratory values come back as follows:

• Hgb-11 Gm
• WBC-10,000 mm³
• Potassium- 4.2 mEq/L
• Sed rate- 10 mm/hr
• Creatinine-5 mg/dL
• BUN-7 mg/dL
• CO₂-15 mEq/L
• UA-small amount of leukocytes, negative nitrites, large ketones
• Blood and Urine cultures-pending
• Blood glucose-75 mg/dL

Mary is stabilized at this time. The nurse sends a repeat UA and the doctor orders an antibiotic by mouth for the patient. Her temperature is now at 99.2^O F rectally and her chest X-ray is positive for left lower lobe pneumonia. The doctor decides to admit Mary for observation and IV fluid therapy.

1. Describe your physical assessment (state where you would start and note normal expected as well as any abnormal findings listed from the case study).

a. Make sure to list all abnormal findings listed in the case study.

Answer 1

1. The given child is 1 year old . she is having pneumonia and dehydration due to vomiting with features of acute kidney injury

physical examination of child

consious , and lethargic due to loss of electrolytes and water from body through vomiting

febrile to touch , weight reduced from past 2weeks value, but within normal range for the age  , due to accute illness and vomiting

head examination - look for anterior frontanalle , it will be more depressed than normal.(normaly mild depressed)

eye - sunken eyes , without tear comming while crying (normaly not sunken , tears occurs while crying)

nose - mild congested , may be this upper respiratory infection which leads to pneumonia (normaly without congestion or secretions )

oral cavity - lips are dry due to dehydration (normaly lips are moist due to saliva produced from minor salivar glands )

chest - hyperventilation present due to pneumonia (normal respiratory rate in 1 year is 24 to 40 breaths per minute)

cvs - apical heart beat within normal limit for this age (normal heart rate for 1 year is 100 to 160 beats per minute ) bp is within normal limits

abdomen - normaly will be soft , nontender

extremities - normaly warm due to adequate vascular flow , and it will be cold in this situation due to dehydration

2 . abnormal findings in the case scenario are

patient is febrile , lethargic, not active , not passed urine for about 12 hour ,

having nasal congestion , dry lips and , no tears even on ocasional cry , hyperventilation .

labotary abnormalities are - serum creatine level is high , 5 mg /dl , may be due to dehydration and reduced urine production. normaly its value are 0.3 to 0.7 mg/dl.

blood co2 level is low , normal value is between 23 to 29 meq/l

urine shows abnormlaity like nitrates , which may be due to aasosiated urinary tract inection.

and presence of ketone , due to the body usage of fat and other products instead of sugar due to acute illness.

other laboratry values like hemoglobin , wbc count , esr , bun , potasium , blood sugar values are within normal limits