Question

BJ is a 10 yr old female of Hispanic origin who presents to your exam room with an adult Hispanic male that identifies himself as her uncle. He states that BJ has hurt her Right arm after falling down the steps the day before. He states she did NOT loss consciousness or injury her head. The providers asks BJ, “How did you fall down the steps?” BJ looks down and softly states, “I just tripped and feel:. Both speak with broken English.

PMI: No hospitalization or Surgeries. Immunization History is unknown.

Medications: None Allergies: None

FH: Parents Living Mother age 24 Father age 30, No Siblings

SH: Both parents work cleaning in the hotel industry. BJ is “home schooled” by her aunt.

ROS:

General: NEG weight loss or gain NEG fatigue, NEG fever

HEENT: NEG for headache, congestion, nasal drainage, vision problems, throat pain

Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness

Resp: NEG Dyspnea, Neg for cough, wheezing, NEG PND

GI: NEG Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia

MS: + R Shoulder Joint pain, +Joint Swelling, + for falls

HEME: + for bruising NEG for bleeding, Neg night sweats

ENDO: Neg for thirst, heat or cold intolerance

NEURO: NEG dizziness, Neg for confusion, numbness, aphasia

PSYCH: NEG for memory loss, Neg for nervousness, suicidal ideation

PE:

General: thin, small for stated age, unkempt but clean in appearance, sitting on exam cradling her R arm in her lap. She winces in pain with any body movement.

HEENT: Normocephalic, long tangled black hair with thin patches of hair loss in occipital area. R Pinnae with purple bruising. TM clear. NEG Weber and Rinne Test. Brown Eyes symmetrical, PERRL, Normal Light Reflex, Normal EOM and Convergence. Nose centered, nares clear with pale, bloody turbinate’s. Throat with clear pharynx, normal tonsils, uvula midline, poor dentition with missing teeth,

NECK: No JVD, Trachea Midline, No Adenopathy, FROM, + Pain with Lateral movement

CHEST: symmetrical, COR: Reg S1S2, No murmurs, rubs, gallops

RESP: CTA with equal bilateral expansion. Significant ecchymosis R sternomastoid muscle into R sub clavicular and post scapular areas

ABD: Ecchymosis in RUQ with tenderness to light palpation. Possible liver enlargement. Bowel Sounds x 4 quadrants

GU: ecchymosis of perineum with vaginal spotting noted on underpants

EXT: No clubbing, cyanosis, pale, sluggish capillary refill in R phalanges nail beds. FROM in LUE & bilateral LE, Severe pain with attempts to abduct RUE. +3 pedal, femoral, brachial, radial pulses

Psych: Alert, Oriented to Place and Time. Quiet, withdrawn mood, Flat affect, avoids eye contact

Vital Signs: HT: 53 inches WT: 60 TEMP: 99 BP: 100/50 HR: 90 RESP 30 O2SAT: 95%

Discussion Questions: What diagnostic tests would you order and why? What referrals would you request? How else can you document/validate your physical findings? What would you do if uncle refused the testing or treatment? Although this is a case of child, this could easily be an elderly 75 year old brought in by a family member. What would you do differently if this an adult?

Answer 1

CBC - To detect the inflammation, loss of blood, and abnormalities.

Chest X-ray - To detect bone structure and joints.

MRI scan - To get a detailed image of soft tissue.

USG whole abdomen - To detect the blood clotting, level of injury on the tissues, organs.

I refer the patient to the orthopedician and internal medicine to find internal bleeding.  I document as acute pain on the right shoulder. pain rate is 6, swelling on the right shoulder. Ecchymosis present on the right chest, RUA, and perineum. Hyperthermia r/t to wound infection. If uncle refused with treatment, then call her parents to explain with them and continue with the treatment. If the patient is a 75-year-old child, then the patient had more chance of getting fracture and care to be focused on the prevention of complications.