Terrell Jeffries MR # 207 · HPI: Terrell Jeffries presented to the ED (emergency department) early this morning accompanied by his parents, Tonya and Thomas Jeffries. Tonya (mother)

Patient: Terrell Jeffries DOB: 07/ 04/xxxx Age: 7 y/o Attending: Dr. James Herrick Allergies: NKDA MR#: 210 Diagnosis: Pneumonia, r/o Acute Chest Syndrome Gender: Male Height: 3’7” Weight: 20.5 kg Sickle Cell Disease BMI: 17.1

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UNLV 01.2020

Terrell Jeffries

MR # 207


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UNLV 01.2020

HISTORY & PHYSICAL Chief Complaint: “My chest hurts.” “I feel hot.” HPI: Terrell Jeffries presented to the ED (emergency department) early this morning accompanied by his parents, Tonya and Thomas Jeffries. Tonya (mother) reports Terrell had a “cold and runny nose” prior to the ED visit but “then he got sick all of sudden coughing” with a reported fever of 102.4˚F. Thomas (father) states, “It was hard for him to breath.” Prior to this hospitalization Terrell was taking penicillin V potassium 250 mg prophylaxis orally twice a day.

It will be discontinued while he is on antibiotic therapy for pneumonia.* *https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/acute-chest-syndrome-clinical-pathway.pdf

Past Medical History: Terrell was diagnosed with sickle cell anemia (SCA) at 3 y/o following a hospitalization for

a severe RSV infection. Terrell was not born in the US and did not undergo routine newborn screening; his

parents were missionary’s working in South America. During Terrell’s first hospitalization both parents were

tested for Sickle Cell Disease (SCD) and were (+) for sickle cell trait. This is only Terrell’s second hospitalization

for a respiratory infection since his diagnosis with SCD.

Terrell has no other major medical illnesses besides SCA; he has had no previous surgeries, trauma, fractures, or lacerations. Only past previous hospitalization was the above mentioned RSV infection 3 ½ years ago. Family HX: Both parents are (+) for sickle cell trait; no previously identified history with sickle cell trait or disease in their families. Tonya and Thomas Jeffries were born in the United States; their parents immigrated to the US from Grenada. Surgical History: None Growth & Development History: Developmental milestones have been met without delays. No unusual behaviors, sleep disturbances, phobias reported by parents.

.

https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/acute-chest-syndrome-clinical-pathway.pdf


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UNLV 01.2020

HISTORY & PHYSICAL (continued)

Social History: Terrell is a second grader in a Clark County School District (CCSD) elementary school. He lives with his parents and a 2 y/o sister, Tamara, who does not have sickle cell trait or disease. Terrell enjoys school and watching soccer with his dad; he just started taking acting lessons. His best friend is “Aiden.” REVIEW OF SYSTEMS GENERAL: Prior to this hospitalization there was no unusual weight gain or loss, change in appetite, or extreme fatigue reported by parents. BMI 17.1 at admission. ALLERGIES: No hay fever, allergic rhinitis, asthma, eczema, drug reactions. HEENT: No headaches/concussions; no conjunctivitis or eye injury. Mother reports a “couple of colds every year” but “nothing like this.” No post-nasal drip or snoring; not a mouth breather. Vision & hearing screening conducted at school last year “normal” per mother. Father reports “sometimes the whites of his eyes look yellow to me.” No ear infections. Sees local pediatric dentist twice a year; no caries or abscesses. SKIN: Dry and itchy skin. No rashes, hives, or hair loss. CARDIOVASCULAR: Tachycardia. No chest pain, heart murmur, cyanosis, fainting. RESPIRATORY: Dyspnea and tachypnea now but not routinely. Does not usually have a cough, congestion/sputum, or wheezes. Currently participates in PE (physical education) at school without limitations or restrictions. GASTROINTESTINAL: Regular formed bowel movements. No diarrhea, constipation, abdominal pain or discomfort. Favorite food is pizza and donuts. GENITOURINARY: Strong urinary stream. No prior urinary tract infections, polyuria, hematuria, abnormalities of penis or scrotum. No priapism. Enuresis “2 or 3 times a week” father reports but “sometimes not at all.” NEUROMUSCULAR: No headache, nervousness, dizziness, convulsions, difficulty walking. Has “aches and pains” of elbows and legs, relieved by NSAIDs (non-steroidal anti-inflammatory) medication and heat packs.


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PHYSICAL ASSESSMENT VITAL SIGNS: T 103.0 F P 118 BPM R 28/MIN BP 90/50 HEIGHT 3’7” WEIGHT 20.5 BMI 17.1 GENERAL APPEARANCE: Lying in bed, responsive and answering questions appropriately. “My chest hurts when I breathe.” Restless, turning from side-to-side. Both parents at bedside. SKIN: Warm, dry to touch. Intact without lesions. Thick, curly black hair, normal distribution. HEENT: Normocephalic, no lesions on scalp. Facial expressions symmetrical. Pupils equal/reactive to light; EOM’s (extraocular movements) intact. Conjunctiva pale; sclera jaundiced. Optic disc visualized. Normal pinna, external appearance of ears. Tympanic membranes pearly white. Hearing grossly intact. Normal nares; nasal septum midline. Yellow nasal discharge present. Teeth in good condition, clean, without caries. Palate intact. Lips & buccal mucosa dry. Tonsils large, red with yellow exudate but adequate gap between them. Gag reflex intact. NECK: Trachea midline, thyroid non-palpable. Tonsillar lymph nodes palpable. ROM intact, no nuchal rigidity. HEART: No ventricular heaves/thrills. S1, S2; no murmurs or abnormal heart sounds heard. Sinus tachycardia. Normal carotid and femoral pulse; popliteal and dorsalis pedis pulses +1 bilaterally. Capillary refill > 2 seconds. LUNGS: Tachypneic; using accessory muscles, nasal flaring. Scattered crackles and rhonchi bilaterally. Tactile fremitus palpable anterior chest. Productive cough with yellow sputum. ABDOMEN: No distention, scaphoid in contour. No tenderness with light palpation. Bowel sounds present. Liver, spleen, kidneys non-palpable. GENITALIA: Circumcised. External genitalia normal in appearance. EXTREMITIES/BACK: No deformities in upper/lower extremities. Both elbows are tender to light palpation, skin warm to the touch; range of motion intact. No edema, asymmetry noted. Muscle tone within normal limits; no rigidity, flaccidity, spasticity noted. Peripheral pulses present bilaterally. No curvatures/rigidity of spine or back noted. Gait steady. NEUROLOGIC: Alert, oriented, & cooperative 7 y/o. Cranial nerves II – XII intact. Patellar deep tendon reflexes + 2 bilaterally. MEDICATIONS

Penicillin V potassium 250 mg orally twice a day

Over the counter medications o Flintstones Childrens chewable multivitamin 1 every day

Assessment: 1. Pneumonia, bacterial versus viral

o r/o Acute chest syndrome 2. Sickle cell disease

Plan: Admit to pediatric in-patient unit; Consult with pediatric pulmonologist Dictated: Today

James Herrick MD

Dr. James Herrick MD


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UNLV 01.2020

PHYSICIAN ORDERS Date Time PHYSICIAN ORDER AND SIGNATURE

Today

Now

Admit to Inpatient Pediatric Unit Diagnosis: Pneumonia, r/o Acute Chest Syndrome Sickle Cell Disease Condition: Stable Droplet Precautions Allergies: NKDA Vital signs:

Every 4 hours as needed

Continuous pulse oximetry Pain assessment: every 4 hours and as needed Pulmonary Toilet:

Aggressive Incentive Spirometer(IS) every hour while awake

Encourage turn, cough, deep breaths and gentle percussion every 2 hours while awake Activity: Ambulation, out of bed, 3 - 4 times per day with assistance, as tolerated Nutrition:

Diet as tolerated

Strict intake & output every shift

Daily weights Nursing Communication: • Call MD for T ≥ 101.0֯ F and not responding to acetaminophen, HR > 120 bpm, and/or SBP > 130 mmHg or < 90 mmHg, and • Call respiratory therapy & MD if O2 sat ≤ 90% and not responding to albuterol/small volume nebulizer treatment (SVN) Saline lock for intravenous medication administration Daily Medications:

Ceftriaxone 1.5 gram intravenous piggyback (IVPB) every 24 hours for 7 days* Discontinue prophylactic oral penicillin while receiving intravenous antibiotics*

Methylprednisolone 5 mg intravenous piggyback (IVPB) every 12 hours for 3 days*

Ranitidine 10 mg intravenous piggyback (IVPB) every 8 hours for 3 days*

Ketorolac 10 mg intravenous push (IV) every 6 hours for 48 hours for pain/inflammation*

Ibuprofen 200 mg po every 6 hours after 48 hours of Ketorolac completed*

Multivitamin 1 po every day

*https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/acute-chest-syndrome-clinical-

pathway.pdf




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Admit to Inpatient Pediatric Unit

Diagnosis: Pneumonia, r/o Acute Chest Syndrome Sickle Cell Disease PRN Medications:

albuterol/Ventolin inhalation solution 2.5 mg dose – 0.5 mL inhalation solution in 2.5 mL 0.9% normal saline via small volume nebulizer (SVN) every 3 hours, not to exceed 6 doses in 24 hours https://www.rxlist.com/ventolin-solution-drug.htm#indications

acetaminophen 220 mg orally every 4 hours as needed, not to exceed 5 doses in 24 hours; for temperature ≥ 101.0 ֯ F

https://www.drugs.com/dosage/acetaminophen.html#Usual_Pediatric_Dose_for_Fever

Morphine 2.0 mg intravenous push (IVP) per 1 dose every 2 – 4 hours for pain not relieved by ketorolac or ibuprofen* *https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/acute-chest-

syndrome-clinical-pathway.pdf

Labs

CBC with differential, platelet & reticulocyte count (done in ED) and daily

Renal & liver function tests (done in ED)

Influenza A & B screening during appropriate season

Type & cross match stat for minor-antigen-matched, sickle-negative, leukocyte-

depleted RBC’s

Blood & sputum cultures (done in ED)

Chest x-ray (CXR) done in ED and repeat for clinical deterioration

Consults

Pediatric Pulmonologist Consult: Children’s Lung Specialists

Child Life Specialist – meet with Terrell, parents re: pain management strategies

Reference:

Pediatric Acute Chest Syndrome (ACS) Clinical Pathway

Children’s Hospital Colorado: March 2, 2017 (next scheduled review 04/17/2020) https://www.childrenscolorado.org/globalassets/healthcare-professionals/clinical-pathways/acute-chest-syndrome-clinical-

pathway.pdf

PROVIDER SIGNATURE:

Dr. James Herrick MD

https://www.rxlist.com/ventolin-solution-drug.htm#indications

https://www.drugs.com/dosage/acetaminophen.html#Usual_Pediatric_Dose_for_Fever






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UNLV 01.2020

NURSING FLOW SHEET

DATE:

VIT

AL

SIG

NS

TIME

BLOOD PRESSURE

PULSE

RESP RATE

TEMP

PA

IN

SCORE

LOCATION

CHARACTER

RES

P

OXYGEN

OXIMETER

NU

TR DIET / % EATEN

SUPP FEEDING

INTA

KE

PO

IV

OU

TPU

T

URINE

DRAINS

PROBLEM / EVENT DOCUMENTATION

DATE / TIME

SIGNATURE


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UNLV 01.2020

MEDICATION ADMINISTRATION RECORD Pg. 1

SCHEDULED MEDICATIONS MEDICATION 0700 - 1859 1900 - 0659

Ceftriaxone 1.5 gram intravenous piggyback (IVPB)

every 24 hours for 7 days*

1400

Methylprednisolone 5 mg intravenous piggyback (IVPB)

every 12 hours for 3 days

1330

0130

Ranitidine 10 mg intravenous piggyback (IVPB) every 8

hours for 3 days

1300

Ketorolac 10 mg intravenous push (IVP) every 6 hours

for 48 hours for pain/inflammation

1200

Ibuprofen 200 mg orally every 6 hours after 48 hours of

Ketorolac completed

SIGNATURE INITIALS SIGNATURE INITIALS


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UNLV 01.2020

MEDICATION ADMINISTRATION RECORD Pg. 2 NON – SCHEDULED MEDICATIONS

MEDICATION 0700 - 1859 1900 - 0659

albuterol/Ventolin inhalation solution 2.5 mg dose =

0.5 mL inhalation solution in 2.5 mL 0.9% normal saline via

small volume nebulizer (SVN) every 3 hours, not to exceed

6 doses in 24 hours

acetaminophen 220 mg orally every 4 hours as needed

for temperature ≥ 101.0֯F, not to exceed 5 doses in 24

hours

morphine sulfate 2.0 mg intravenous push (IVP) per 1 dose every 2 – 4 hours for pain not relieved by ketorolac or ibuprofen

SIGNATURE INITIALS SIGNATURE INITIALS


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UNLV 01.2020

LAB STUDIES & DIAGNOSTICS

HEMATOLOGY: Age Adjusted 7 – 12 years LAB TEST NORMAL RANGE PATIENT VALUE

Red Blood Cells (RBC) Males: 4.0 – 5.2 106/mm3 Females: 4.0 – 5.2 106/mm3

3.9

Hematocrit (HCT) Males: 35 – 45% Females: 35 – 45%

34

Hemoglobin (HgB) Males: 11.5 – 15.5 g/dL Females: 11.5 – 15.5 g/dL

11.3

White Blood Cells (WBC) Males: 5.0 – 14.5 103/mm3 Females: 5.0 – 14.5 103/mm3

16.000 103/mm3 (H)

Platelets (Plt) Males: 150,000 – 450,000 103/mm3 Females: 150,000 – 450,000 103/mm3

250,000

Mean Corpuscular Volume (MCV)

76 – 90.0 fL

76

Mean Corpuscular Hemoglobin Concentration (MCHC)

32 – 36.0 g/dL

32

Reticulocyte count 0.5 – 1.5%

3.0

Reference: Appendix B, Pediatric Normal Laboratory Values

https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781444345186.app2



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UNLV 01.2020

LAB STUDIES & DIAGNOSTICS Complete Metabolic Panel: Age Adjusted

LAB TEST NORMAL RANGE PATIENT VALUE Sodium (NA+) 136 – 145 mEq/L

145

Potassium (K+) 3.5 – 5.0 mEq/L

3.6

Chloride (CL-) 95 – 105 mmol/L

80

Carbon Dioxide (C02) 24 – 30 mmol/L

24

Magnesium (Mg++) 1.6 – 2.3 mg/dL

2.1

Glucose 70 – 110 mg/dL

91

Calcium (Ca++) 8.8 – 10.1 mg/dL

9.3

Phosphorous (P04) 3.1 – 6.3 mg/dL

4.5

Blood Urea Nitrogen (BUN) 8 – 25 mg/dL

15

Creatinine 0.12-1.06 mg/dL

0.7

Osmolality 275 – 295 mOsm/kg

293

Albumin 3.7 – 5.5 g/dL

4.2

Pre-Albumin 18 – 44 mg/dL 21

Ammonia 22 – 48 umol/L

30

Bilirubin 0.2 – 1.0 mg/dL

1.0

Conjugated Bilirubin <0.35 mg/dL

0.21

Alkaline Phosphatase 175-420 U/L

225

AST (aspartate aminotransferase)

15 – 40 U/L 30

ALT (alanine aminotransferase)

10 – 35 U/L

21

Amylase 30 – 115 U/L 50

Lipase 25 – 120 U/L 61 Reference: Appendix B, Pediatric Normal Laboratory Values




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UNLV 01.2020

LAB STUDIES & DIAGNOSTICS LIPID PANEL

LAB TEST NORMAL RANGE PATIENT VALUE

Triglycerides 20 – 150 mg/dL

75

LDL (low-density lipoprotein)

Males: 64 – 130 mg/dL Females: 60 – 140 mg/dL

111

HDL (high-density lipoprotein)

Male: 38 – 75 mg/dL Female: 35 – 73 mg/dL

57

Total cholesterol 135 – 200 mg/dL 144

LAB STUDIES & DIAGNOSTICS ARTERIAL BLOOD GAS, completed in ED

LAB TEST NORMAL RANGE PATIENT VALUE

pH 7.35 – 7.45 7.36

PaC02 38 – 45 mmHg 40

Pa02 75 – 100 mmHg 96

Sa02 94 – 100% 95

HCO3 22 – 28 mEq/L 24 Reference: Blood Gases/Medical Tests/UCSF Benioff Children’s Hospital

https://www.ucsfbenioffchildrens.org/tests/003855.html

https://www.ucsfbenioffchildrens.org/tests/003855.html


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UNLV 01.2020

URINALYSIS – Pediatric, completed in ED LAB TEST NORMAL RANGE PATIENT VALUE

Color Yellow Yellow

Appearance Clear Clear

Specific Gravity 1.001 – 1.035 1.036

pH 4.0 – 9.0 6

Occult Blood Negative Negative

Glucose Negative Negative

Protein Negative Negative

Ketones Negative Negative

Bilirubin Negative Trace

Urobilinogen <2.0 <1.0

Nitrite Negative Negative

Leukocyte esterase Negative Negative

Microscopic Urinalysis

White blood cells 0 – 4/HPF 0

Red blood cells 0 – 4/HPF 0

Epithelial cells 0 – 4/LPF 0

Bacteria Few 0

Hyaline Casts None seen None seen

Granular Casts None seen None seen

Crystals None seen None seen

Reference: Appendix B: Pediatric Normal Laboratory Values – Wiley Online Library https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781444345186.app2



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UNLV 01.2020

IMAGING

XRAY Admitting diagnosis: Presented with fever, cough; history of sickle cell disease.

Impression: New pulmonary infiltrate on CXR consistent with alveolar consolidation. Significant infiltrate in right middle & lower lobe of the lung and part of the right upper lobe.

Jackson Schmidt, MD

Radiologist Rebel Hospital of Southern Nevada Reference: https://theijcp.org/tables/ijcp4wt.htm#outF3 International Journal of Clinical Pediatrics

https://theijcp.org/tables/ijcp4wt.htm#outF3nt


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UNLV 01.2020

The following is the form of a “Declaration,” provided for under Nevada Statues:

DECLARATION If I should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment. I direct any attending physician, pursuant to NRS 449.535 to 449.690, inclusive, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain. If you wish to include the following statement in this declaration, you must INITIAL the statement in the box provided:

Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. Initial this box if you want to receive or continue receiving artificial nutrition and hydration by way of gastrointestinal tract after all other treatment is withheld pursuant to this declaration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |_____|

Signed this _________________ day of _____________, 19______. Signature: _____________________________ Address: ______________________________

______________________________ ______________________________

The declarant voluntarily signed this writing in my presence. Witness: ______________________________ Address: ______________________________ Witness: ______________________________ Address: ______________________________


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UNLV 01.2020

The following is the form of a “Durable Power of Attorney for HealthCare Decisions” provided for under Nevada Statute:

DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS WARNING TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document. It creates a Durable Power of Attorney for HealthCare. Before executing the document you should know these important facts: 1. This document gives the person you designate as your Attorney-in-Fact the power to make health care

decisions for you. The power is subject to any limitations or statement of your desires that you include in this document. The power to make health care decisions for you may include consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. You may state in this document any types of treatment or placements that you do not desire.

2. The person you designate in this document has a duty to act consistent with your desires as stated in this document or otherwise made known, or, if your desires are unknown, to act in your best interest.

3. Except as you otherwise specify in this document, the power of the person you designate to make health care decisions for you may include the power to consent to your doctor not giving treatment or stopping treatment which would keep you alive.

4. Unless you specify a shorter period in this document, this Power will exist indefinitely from the date you execute this document and if you are unable to make health care decisions for yourself, this power will continue to exist until the time when you become able to make health care decisions for yourself.

5. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped if you object.

6. You have the right to revoke the appointment of the person designated in this document to make health care decisions for you by notifying that person of the revocation orally or in writing.

7. You have the right to revoke the authority granted to the person designated in this document to make health care decisions for you by notifying the treating physician, hospital, or other provider of health care orally or in writing.

8. The person designated in this document to make health care decisions for you has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

9. This document revokes any prior Durable Power of Attorney for Health Care. 10. If there is anything in this document that you do not understand, you should ask a lawyer to explain it to

you.


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UNLV 01.2020

1. DESIGNATION OF HEALTHCARE AGENT I, _________________________________ (insert your name) do hereby designate and appoint: Name: Address: Telephone Number: As my attorney-in-fact to make health care decisions for me as authorized in this document. (Insert the mane and address of the person you wish to designate as your attorney-in-fact to make health care decisions for you. Unless the person is also your spouse, legal guardian or the person most closely related to you by blood, none of the following may be designated as your attorney-in-fact: (1) your treating provider of health care; (2) an employee of your treating provider of health care; (3) an operator of a health care facility; or (4) an employee of an operator of a health care facility.)

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE By this document, I intend to create a Durable Power of Attorney by appointing the person designated above to make health care decisions for me. This power of attorney shall not be affected by my subsequent incapacity.

3. GENERAL STATEMENT OF AUTHORITY GRANTED In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the attorney-in-fact named above full power, and authority to make health care decisions for me before, or after my death, including: consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat physical or mental condition, subject only to the limitations and special provisions, if any, set forth in paragraph 4 or 6.

4. SPECIAL PROVISIONS AND LIMITATIONS (Your attorney-in-fact is not permitted to consent to any of the following: commitment to or placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. If there is any other types of treatment or placement that you do not want your attorney-in-fact’s authority to give consent for or other restrictions you wish to place on your attorney-in-fact’s authority, you should list them in the space below. If you do not write any limitations, your attorney-in-fact will have the broad powers to make health care decisions on your behalf which are set forth in paragraph 3, except to the extent that there are limits provided by law.) In exercising the authority under this Durable Power of attorney for HealthCare, the authority of my attorney-in-fact is subject to the following special provisions and limitations:

_________________________________________________________________________________ _________________________________________________________________________________

Documents

Terrell Jeffries MR # 207 · HPI: Terrell Jeffries presented to the ED (emergency department) early this morning accompanied by his parents, Tonya and Thomas Jeffries. Tonya (mother)