Daniel DeMarco SOAP Note #2 Pediatrics

 

S

 

BW is a 15yo Male with no PMH admitted yesterday for bloody stools and abdominal pain in the setting of HSP. He has been hypertensive since admission. This morning he states his abdominal pain is being controlled with morphine, which he required 3x overnight. He reports one stool overnight which had “less blood than before.” He states the rashes on his upper and lower extremities have been stable. Denies headaches, vision changes, eye pain.

 

O

 

V/S

T 37.5C (36.4 – 37.5)

HR 112bpm (98-125)

RR 20bpm (17-22)

SpO2 95%RA (95-97)

BP 144/96 (138/86 – 170/117)

Wt: 69.1kg

 

I/Os

Ins: 1.4x MIVF

Outs: 0.90 cc/kg/hr

 

Labs

UA: Negative for protein. RBC 2 (0-2 is Ref Range).

 

PE

General: AOx3. NAD.

Skin: Bilateral upper and lower extremities with diffuse rash. Palpable purpura at ankles. Upper extremities with maculopapular rash. Warm, moist.

Eyes: PERRLA. EOMI and nonpainful. No papilledema.

Heart: RRR. Normal S1, S2. No m/g/r.

Chest: CTAB. No rhonchi, crackles, wheezes.

Abdomen: Nondistended. BS+. Soft. Minimal tenderness in epigastric region. No organomegaly. No masses.

Extremities: No clubbing, cyanosis, edema. Full range of motion.

Neuro: CN II-XII intact. 

 

A

 

BW is a 15yo Male admitted for bloody stools and abdominal pain in the setting of HSP that is improving and hypertension that is not improving.

 

P

 

#HSP

– Cont. IV Methylprednisolone 18mg q6h IV

– Will follow lab results for HepB, HepC, Quantiferon Gold, ANA, anti-dsDNA, ANCA panel

– Appreciate Cornell Pediatric Rheumatology recommendations

 

#Abdominal Pain 2/2 HSP

– Cont. APAP IV single dose q6h

– Cont. Morphine IV 5mg q4h prn

– Cont. Maalox 20mL q6h alternating with Sucralfate

– Cont. Sucralfate 1g q6h alternating with Maalox

– Appreciate Pediatric GI recommendations

 

#HTN ?2/2 HSP

– Cont. Nifedipine 10mg PO q6h

– Start Hydralazine 10mg IV q4-6h. May titrate up by 5mg if BP remains >140/90 to maximum per dose of 20mg

– CMP, C3/C4, Renin, Aldosterone, Urine Microalbumin:Cr Ratio

– Renal U/S with Doppler to assess renal vasculature

– Strict I/Os

– Appreciate Cornell Pediatric Nephrology recommendations

 

#FEN/GI

– Cont. D5NS w/ 20KCl @ MIVF (100cc/hr)

– D/C NPO

– Start Clear Liquid Diet

 

Disposition: Given GI bleed, abdominal pain, and HTN in the setting of HSP, will require >2d inpatient stay. Will require Rheumatology, GI, and Nephrology input.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student