Patient:XXX
FOCUS
CEREBAL PALSY (CP), C-DIFF INFECTION, GASTROENTERITIS

PATIENT DESCRIPTION

XXX IS AN 8 YEAR OLD CHILD WITH SPECIAL NEEDS WHO WAS ADMITTED TO THE HOSPITAL TODAY WITH AN INFECTION IN HER GUT.  SHE HAS ABDOMINAL PAIN, FEVER, LOOSE/MUCOUSY DIARRHEA AND LOSS OF APPETITE,BUT MOST IMPORTANTLY, SHE’S SHOWING SIGNS AND SYMPTOMS OF DEHYDRATION.  XXX IS ACCOMPANIED BY HER MOTHER WHO STATES, “SHE’S NOT ACTING LIKE HERSELF: I’M WORRIED SHE MAY BE GETTING DEHYDRATED WITH ALL OF THE DIARRHEA SHE’S HAVING, “YOUR CLINICAL ASSESSMENT AND DECISION MAKING SKILLS ARE CRITICAL FOR XXX’S OUTCOME.  CAN YOU HELP XXX?

XXX’S MEDICATIONS

DEXTROSE 5% IN 0.9% NACL
4 ML DIAZEPAM 0.005 MG/MG PREFILLED APPLICATOR (DIASTAT)
BENZTROPINE MESYLATE 1 MG/ML INJECTABLE SOLUTION (COGENTIN)
PHENYTOIN SODIUM 100 MG EXTENDED RELEASE ORAL CAPSULE (DILANTIN) 

INCLUDE:
HEENT
HEAD- TO- TOE ASSESSMENT
LAB/VITAL SIGNS
MEDICATE PATIENT WOUND CARE
ANY OTHER ISSUES