Patient Assessment - Deep trouble

karenG · Jun 14, 2003

hey Peeps......it could have been cholycystitis- think referred pain. but would be low on my list of differential diagnosis

K

kids · Jun 14, 2003

Originally posted by canadian
A: kiddie 4 yrs old 3day Hx malaise and cough, dehyrated, temp 38.8

B: kiddie 4 years old on Tx for ALL temp 38.3 no other Sx.

Kiddie A: His fever isn't terribly high (101.8 F) when was his last dose of an antipyretic? No mention of vomiting/diarhhea, dehydration likely due to poor intake rather than excess loss. No mention of rash. No mention of nasal drainage.

Probably a viral syndrome...possibly OM, might want to do a strep but unlikely (fever

Kiddie B: Temp not to bad, 100.9 F. no complaints. On tx for ALL.

DING DING DING... we have our admit...find the kid a bed away from sick people, he's neutropinic, get blood cultures and a line going...this kid could be in the toilet very quick.

Oh...and get kiddie A a Pedialyte popcicle.

The risks to Kiddie B in not being worked up first are greater than they are to kiddie A.

mare-mare · Jun 15, 2003

What is the answer to case 6???? I'm dying to know... I think he has some sort of cervical injury and is at risk for losing his airway to swelling soon...

karenG · Jun 15, 2003

Originally posted by kids-r-fun
Kiddie A: His fever isn't terribly high (101.8 F) when was his last dose of an antipyretic? No mention of vomiting/diarhhea, dehydration likely due to poor intake rather than excess loss. No mention of rash. No mention of nasal drainage.

Probably a viral syndrome...possibly OM, might want to do a strep but unlikely (fever

Kiddie B: Temp not to bad, 100.9 F. no complaints. On tx for ALL.
DING DING DING... we have our admit...find the kid a bed away from sick people, he's neutropinic, get blood cultures and a line going...this kid could be in the toilet very quick.

Oh...and get kiddie A a Pedialyte popcicle.

The risks to Kiddie B in not being worked up first are greater than they are to kiddie A.

oh I am so glad someone agreed with me!! was starting to think I was way off beam!!

Karen:)

gwenith, BSN, RN · Jun 16, 2003

Thanks for answering the paeds one for us Kids-R-fun.

Case 6

He in all probability has a fractured larynx - they are rare but I have coem across a couple in my time. the keys re teh stroy -caught across teh throat - "clothes lined" by a branch while traveling at speed. The second is the hoorifice voice and the third and most important is the stridor.

By the time stridor is audible in an adult they only have 20-30% of the airway patent in other wards they are 70-80% occluded. Stridor is always a danger sign. This patient will and should be taken immediately to threatre and a tracheostomy performed. Nebulised adrenaline may be given and in extreme circumstances I have seen helium oxygen mix used on upper airway obstruction but the botom line will be a trachy.

Whisper · Jun 16, 2003

I was starting to worry as well! I have very little experience at admitting people, I have either watched others or on one placement they said here you do it and I missed big things.

I knew there was something wrong with both patients and I went and harrasessed a doctor, the nurse who was suposed to be supervising me wasn't interested, If either of these guys decide to sue, the care plans and assessment forms were all completed by me, and she just countersigned without reading...

1. Admited for R&r (This was a private hospital). TPR and BP NAD. Only complaint a slight rash, Wife said she had changed washing powders and he was taking piriton. The guy looked zonked(Sorry no technical terms,) bu this cold have been the piriton, but was alert and able to participate in the assessment whenever his wife let him.

Two days later this gentleman went into renal failure and was blue lighted to the NHS, before this he was amitted to the private HDU, and I did get the Dr to do Bloods, none had been ordered, and I gave up my break to treck across to the NHS hospital to get instant blood gasses.

Next time I'll tell the wife to shut up, and drag an Rn in, even if it is screaming and kicking!

Can any of you guess what was wrong with this chap?

Peeps Mcarthur · Jun 16, 2003

Piritin chlorpheniramine maleate, an antihistimine.

I don't have a PDR handy , but I imagine that the rash is from something other than a simple reaction. Rash is seen as an reaction to antihistimines but not renal failure.

From his "zonked" presentation I would say that he may have liver disease. The antihistimine, which he was showing a reaction to with the rash, built up from an inability to metabolize it fully, and the reaction to the antihistimine was manifested systemicaly as its serum concentration built up.

That's all I can come up with.

I'm late to class again .................crap.

Love this stuff.

Whisper · Jun 16, 2003

I checked with the BNF and Piriton, chlorphenamine maleate/ chlorpheniramine maleate.

One of the main side effects is sedation, so I was thinking logically at the time.

Rash from washing powder --->o/c remedy--> Side effect--> lethargy (I thought of another word instead of zonked;))

This was all the gentlemen presented with, and to be honest I gave a big clue with blood gasses, and the fact he went into renal failure.

I am going back to my work, and I'll post his diagnosis later.

Whisper

Peeps Mcarthur · Jun 17, 2003

All blood gasses will tell you is that he is in metabolic acidosis. That can be assumed from renal failure since the kidneys produce bicarb to buffer. He is in no apparent distress, just lethargic, so I can't see the gasses giving you a respiratory indication..............unless his co2 was not compensating(

uhmmm.

OOOOOOOk,

gotta study

Whisper · Jun 17, 2003

Quickly posting his diagnosis before I go to work,

The gentleman had Septicemia, he was 'zonked' as a combination between this and the sedation from the piriton. I wasn't happy to complete this assessment, and there was somehting about this guy I could just not put my finger on, when the Rn wasn't bothered I talked the doc into going and seeing him first, pushing him to the front of the queue, the blood gasses weren't that important on his admittence, but they did come back with slightly altered levels, enough to bumb the guy up to a higher level of care, by day one he was going down hill fast, diagnoises confirmed, and moved to a HDU bed, over night renal failure began to show, and Gentleman was starting to circle the drain... Blue lighted over to the NHS HDU/ICU, and treated for renal failure (1st stage).

He did make a full recovery, but he was in hospital for a long time... Now anyone that even gets an allergy from the sheets, if the RN won't listen I ring dermi. just to ask their advice.

Got to run

Whisper

RachelKieran · Jun 17, 2003

I am amazed at how much you guys know. Peeps - how come you know so much!!?? Although I suppose once something grabs my attention I can run with it - just haven't had much opportunity to at this stage in my degree. (although I can tell you a fair bit about impetigo - but you probably already know it!!!).

gwenith, BSN, RN · Jun 17, 2003

Whisper - Sepsis in the elderly can be very difficult to diagnose. What kind of rash did he have? When you said rash it did run through my mind that it could be anything from peticheal spots to a severe allergic reaction. The following flow chart shows how complex "rash" can be.

http://familydoctor.org/flowcharts/545.html

Although sepsis usually have a high temp there are cases especially in the elderly who do not evidence a high temperature. Often early shock (septic and hypovolaemic) can associated wth respiratory alkaloisis. But it depends on the stage of shock as to the effect seen in the blood gases.