Comprehensive Soap: Child Maltreatment

Present Concerns/CC: “TA has been refusing to eat and has been whining, and I think he is trying to say his stomach is hurting.’

TA sleeps for about eight hours and takes an afternoon nap every day. He also brushes his teeth alone and washes his hands with soap and water. He enjoys watching cartoons but is not involved in any sports activities. TA was a full-term baby born via vaginal delivery. He was diagnosed with Down syndrome at birth. He has delayed developmental milestones. He has not started talking well. His growth is retarded, he is poor at understanding things and is very slow.

TA was well until two days ago when he started whining and refusing to eat any food because of abdominal pains. My boyfriend says that TA fell from the bed when taking a nap and that is when all the problems started. The pain is associated with low energy levels, withdrawal from activities, reduced urine frequency and bowel movements, and abridged feeding. His pain is constant and is worse when he is touched or lifted but nothing alleviates it. He does not have diarrhea or blood in the stool. The mother says that TA has never had any problem like this before.

None

Allergies: None

Medical Intolerances: No known drug hypersensitivity

Chronic illnesses/major trauma: TA was born with Down syndrome and Atrial septal defect. He has no other chronic conditions. TA is very clumsy and is prone to falling and tripping over things and hurting himself from them. He has never severely injured himself or sustained any fractures.

Hospitalization/surgeries: He was hospitalized when he had his heart operation for treating congenital heart defects.

Immunizations: Vaccinations are up to date.

Mother- Has anemia

Biological father- unknown health status.

Elder brother-Has asthma

Youngest step-brother- no known chronic illness.

TA does not attend any daycare setting and is sometimes taken care of by the neighbors or the stepfather. TA lives with the mother and two siblings. His mother separated from his biological father, and now, the stepfather who is the father of the last born child comes and stays over sometimes. The mother is a high school graduate and works as a cashier. Both the mother and the boyfriend smoke, and TA and his siblings are exposed to secondhand smoke. They do not have guns at home, and their community is free from gangs. The water in their area is also clean and free from lead and other harmful substances.

The mother says that TA is not sleeping well and has low energy. She says TA has not experienced any pyrexia, night sweating, and the difference in his weight.

She says that TA is not experiencing any edema, cyanosis, palpitations, or reduced tolerance to exercise.

Apart from diaper rash once in a while, the child does not have any skin problems like rashes or moles.

She says TA has been breathing fast. She, however, denies a cough, sputum production, dyspnea, or wheeze.

The patient does not have any vision problems and does not wear corrective lenses.

The mother says that TA has had abdominal pain, one episode of vomiting, and reduced bowel movements. However, she denies any blood in the stool and diarrhea.

The patient has no hearing problems.

The patient has reduced number of urine diapers. She states that his urine is dark and has a strong smell but denies any blood in the urine or pain when urinating.

TA has congestion many times. He denies any oral lesions, throat pain or difficulty in swallowing.

The mother says that TA does not have any muscle or joint swelling, pain, or stiffness.

She says his breast tissue is normal.

The patient does not have any seizures, tremors, limb weakness, or fainting episodes.

TA gets easily bruised from playing when he trips but has denied any increased bruising, bleeding gums, or sites of abnormally increased bleeding. He has no lymphadenopathy. The mother says he is sweaty and clammy but denies any heat or cold intolerance, frequent urination, and increased thirst.

The mother says that TA is not the typical happy boy and that he is withdrawn.

The child is a 26-month-old baby holding his tummy and is crying. The child is a bit fussy and does not seem to respond much even as the mother talks to him. However, he is not in any acute distress.

His skin is cold, mottled, and sweaty. He has circumferential marks on his wrist consistent with ligature marks. He also has a diffuse diaper rash.

Head: no signs of trauma. He has Down syndrome facial features with an upslanting eye and a flat face. Eyes: The sclera is clear with no icterus, and he has no conjunctival pallor. Ears: normal external ears with no edema or discharge. The tympanic membrane has no signs of hemotympanum and is intact. Nose: has no discharge, polyps, and sinuses are not tender. The neck has no scars, and there is no lymphadenopathy. Throat: no hoarseness, oropharynx not injected, tonsils without exudates, normal gag reflex, and he has dental caries, and his breath is normal.

PMI nondisplaced. Normal JVP. S1 and S2 audible but with an early systolic murmur. TA has a weak pulse. He had no peripheral edema. He has a delayed capillary refill on the toes (four seconds).

Nonlaboured chest movement. Thoracotomy scar present. The chest wall is not tender. On percussion, the lung fields are resonant. On auscultation, the breath sounds are clear.

Ecchymoses are overlying the epigastrium measuring 10cm and oval. He has a distended abdomen. He also has a 2cm reducible umbilical hernia. On auscultation, the bowel sounds are reduced on all quadrants. No tympany or shifting dullness.

Deferred exam

Atraumatic. He has a diffuse diaper rash. His external genitals are normal with a circumcised penis. Both testes are non-tender and descended. There is no evidence of inguinal herniation. Rectum has no fissures or lesions.

TA has no overt limb deformities. The limbs move spontaneously but weakly. There are no focal deficits. Ligature marks on both wrists. There is no localized pain on palpation of the extremities. The muscles have normal bulk and no rigidity or signs of trauma and with a full range of movement.

The patient has normal deep tendon reflex. Balance test and gait exams were not performed for this patient.

The patient seemed anxious, having poor concentration. He was a withdrawn and cried a lot.

Urinalysis- pending, this helps to check if there is any cause of change in the urine such as UTI.

Complete blood count– The assesses for extreme out-of-range values such as leukocytosis or leucopenia which may be used in treatment or to guide resuscitation raised white cell count

Comprehensive metabolic panel– pending, checks for any alteration in the electrolytes, dehydration, and renal function.

Venous blood gases– to assess the effectiveness of oxygen and carbon dioxide exchange and acid/base balance that are critical indicators of tissue perfusion (Kodner & Wetherton, 2014).

Gross motor: The patient can move all his limbs well though the movements are weak. Fine motor: the patient cannot follow moving objects like fingers. Language: TA cannot talk neither pronounce words correctly. Social: TA is a socially withdrawn child and shows signs of depression, and he does not interact with other kids even his siblings.

· Primary Diagnosis: Child abuse T76.12XA. The patient was brought to the emergency room following blunt trauma to his abdomen. The history does not connect with physical findings. Skeletal survey radiographs reveal rib fractures at different healing phases (Jacobi et al., 2013). Furthermore, the child is left with uncaring neighbors and also the mother’s boyfriend is reluctant to take care of them and hates crying babies.

· Volvulus K56.2: This differential can be considered because the child came with abdominal pain and distention. He also presented with signs of shock such as hypotension, and a weak pulse typical for this disease. Volvulus may cause twisting of the colon and lead to acute bowel obstruction. The patient, however, did not have bloody stool and constipation which are found in volvulus.

· Hirschsprung disease Q43.1. The pertinent positives abdominal pain, distension, vomiting, and shock. The negatives were a history of constipation and diagnosis at birth is most often frequent. This diagnosis is associated with Down’s syndrome and is a cause of acute abdomen in children.

The patient should be admitted and resuscitation and stabilization established through assessing airway, breathing, and circulation. He should receive oxygen supplementation and an IV access established for fluid administration. The patient has a need for ICU admission for advanced care. A social worker should be consulted on this case so that the police and CPS are informed of the possible physical child abuse (Christian, 2017).

Vaccines administered this visit: No vaccine was given during this visit as the patient’s immunization is up-to-date.

Vaccine administration forms given: None

Medication– None

Laboratory tests ordered- None

Diagnostic tests requested– Skeletal survey– to assess if the patient sustained any broken bones after the fall or the trauma. Head CT– to assess for a tissue injury to the brain. CT abdomen with IV contrast– This series is done to confirm what is causing the pains in the abdomen. Showed central area of edema with a hematoma (Jacobi et al., 2013).

Patient education including preventive care and anticipatory guidance

The mother should be educated on signs to watch for in case the child or children are being abused at home by the boyfriend or neighbors. These signs include ligature marks on wrists, broken ribs, scratch marks on the child’s forehead, and also symptoms such as withdrawal, anxiety, and refusal to eat or drink (Smith, Robinson, & Segal, 2017). The parent must be advised on the importance of a 24-hour surveillance on young children such as TA who cannot report such issues, and, thus, she should watch them as much as possible to avoid such cases (Jacobi et al., 2013).

Non-medication treatments: none

A follow-up appointment with a detailed plan: This child should be followed up and monitored by CPS which will watch him on a weekly basis and report any issues such as neglect or physical abuse that may warrant an investigation and prosecution (Mcdonald, 2007).