Smith, Jimmy

DOB: 8/15/2020 (5 months old)

Height: 26 inches, Weight 7 kg

Allergies: NKDA

Jimmy was brought to his pediatrician’s office this morning because his mother, Katie, thought he “wasn’t acting right.” The pediatrician was concerned and sent him to the ER. You are assuming care of Jimmy in the ER when he arrives. He has a peripheral IV in place and has D5 0.9% NaCl IV fluids running.

Past Medical & Birth History: Jimmy was born by spontaneous vaginal delivery at 35-weeks gestation. He required monitoring in the NICU for three nights, but did not require a feeding tube or oxygen. He was sent home with no medications. He has been developing normally according to his pediatrician. He has received one dose of hepatitis B, but no other vaccines. He is otherwise healthy.

Past Surgical History: No surgeries.

Social History: Jimmy is an only child. His mother Katie is 19 years old. Jimmy’s father Tony is involved and visits a few times per week. Katie says that she and Tony “fight a lot.” Katie lives with her mother Janet, who took early retirement to help care for the baby while Katie finishes school. Katie is currently in her senior year of high school.

Presentation: Katie says that Jimmy started “acting weird” yesterday. Janet encouraged Katie to call the pediatrician, who had them come in, but promptly sent them to the ER after a quick physical exam. Katie is withdrawn and tearful. Janet is on her way to the hospital.

Neuro: Jimmy is asleep in his crib, whimpering softly and grimacing, and stirs as you unwrap his swaddle. He opens his eyes very briefly then immediately goes back to sleep. He moves all of his extremities weakly to light touch with little antigravity movement. Pupils PERRLA 5mm round and brisk. He begins to cry weakly and is not easily consoled. His fontanel is rounded and full, open, and soft. Katie is irritated that you made him cry.

CV: Heart sounds S1, S2, no murmur. No edema. Pulses +2 in upper and lower extremities. Cap refill < 2 seconds.

Vitals    HR 160     RR 40             Sat 97% on room air        BP 76/38           Temp 37.1 C

Resp: Clear and equal breath sounds. No accessory muscle use. Clear, watery rhinorrhea present. No cough.

GI: Abdomen soft, nondistended. Normal bowel sounds. Katie says he had a loose brown stool yesterday. He drinks iron-fortified infant formula from a bottle.

GU: Katie says he had one small wet diaper this morning. He is circumcised.

Skin: Skin is intact, pink, normal skin turgor. Mucous membranes are tacky.

Pain: Jimmy occasionally grimaces and softly whimpers in his sleep. His legs are in relaxed position. He is lying in a relaxed position and is moved easily during your exam. When he is whimpering and grimacing, and when he begins to cry during your physical exam, he is not easily consoled.

You check your orders and notice he is ordered for a chest x-ray, an electrolyte panel, a POC glucose, a CBC with blood culture, urine culture and urinalysis, and COVID, RSV, and Flu nasal swabs.

Questions related to your new admission:

1. What is Jimmy’s pain score?

2. Review Jimmy’s vital signs and physical exam. Highlight the abnormalities and concerning findings. What are your concerns? What are possible causes of his findings?

3. What developmental milestones are expected for a child this age?

4. What percentile is Jimmy’s height and weight? Use the World Health Organization growth chart and do not adjust for gestational age.

5. How do you plan to prioritize and execute the doctor’s orders?

6. Katie wants to know why he needs tests and blood work. Explain the reasoning for the tests and blood work to her.

7. What other questions would you like to ask Katie about Jimmy’s current situation?

You decide to obtain some more detailed history from Katie. Katie fed Jimmy in the morning yesterday before she went to school. She didn’t get much sleep since he’s been teething and not sleeping well. Katie co-sleeps with Jimmy. Janet watched Jimmy while she was at school. Tony came to visit him for an hour in the late morning when he got off of his night shift. When she returned from school, she says Jimmy was more irritable than usual in the afternoon and was not interested in his bedtime bottle. He slept through the night, which was atypical since he usually wakes once during the night to feed. This morning he was having trouble staying awake and only drank half of his morning bottle. He seems to still have a strong suck. No one around him has been sick lately and there have been no COVID exposures that they know of. He hasn’t had a fever at home that they’ve noticed. His nose has been running but they think it’s because he’s teething.

8. What education can you give Katie about safe sleep?

9. What other education would be helpful to give Katie while you wait for his lab results? (Look at his past medical & birth history)

His lab results came back.

He is COVID, Flu, and RSV negative.

His urinalysis shows clear, yellow urine with no leukocytes, no nitrites, no ketones, no glucose, and no proteinuria.

His blood work shows:

Complete Blood CountBasic Metabolic Panel 
RBC 4.6 mil/ulNa 135 meg/lMg  1.8 mg/dl
WBC 6 K ulK 3.9 meq/lPhos 3.5 mg/dl
Hgb 9 g/dLCl 100 meq/l 
HCT 28%CO2 28 meq/l                
Plt 150,000BUN 5 mg/dl 
 Cr 0.3 mg/dlGlucose 143 mg/dl

His blood culture and urine culture are pending.

Janet arrives as the x-ray tech is entering the room. She tries to get an update from Katie, but Katie doesn’t remember what the labs mean. Janet criticizes her for not paying closer attention.

10. Janet asks you for an update on the results from his blood work. Highlight the abnormal findings. Explain the lab results to Janet in a way she can understand, with Katie’s permission.

The x-ray is taken. 20 minutes later, the radiologist read is:

Anterior-posterior x-ray of the chest shows clear lung fields without infiltrates. Equal diaphragm expansion. No pleural effusion or pneumothorax. Nondisplaced fractures of bilateral ribs 7, 8, and 9.

11. What is concerning about the x-ray results? Notify the provider of the results using SBAR.

12. Based on your conversation, the provider consults an ophthalmologist to examine Jimmy. Why would an ophthalmology exam be helpful?

13. The provider also orders a CT scan of the head. Katie asks you if it will hurt him. What preparation/education do you give Katie about how CT scans are performed?

The CT scan is performed. The read shows:

Non-contrast CT scan of the brain. The brain is normal in anatomy and size. Ventricles are appropriate size. Bilateral moderate subdural hematomas with L greater than R, with signs of mass effect and 1cm L->R midline shift. There are signs of old and new blood, suggesting various ages of bleeding.

14. What is the difference between a subdural and epidural hematoma? What causes each of them? How do they present differently?

Based on these findings, the provider asks the social worker to see the family to assess the dynamic. The provider explains to Janet and Katie that Jimmy is “acting weird” because he has a collection of blood around his head that can result from a variety of causes, including being shaken. Janet becomes defensive and says “There is no way he was shaken. We all know better than to do that. There must be another explanation.” Katie looks downcast.

15. How do you plan to maintain a rapport with this family after accusing them of child abuse?

The provider explains to the family that Jimmy will undergo a workup to explore other causes of subdural hematomas and rib fractures to see if he has an undiagnosed condition like osteogenesis imperfecta or a bleeding disorder. He will also have “Skeletal Survey” meaning x-raying every bone to look for additional fractures. In the meantime, the provider asks you to file the child abuse report while the social worker contacts the police.

16. Draft your child abuse report narrative here. It should be thorough, unbiased, impartial, and reporting only the facts, patient history, and physical exam findings as you understand them.

17. Who do you think shook Jimmy? Does it matter?

18. Do you have any moral or ethical feelings about the situation that could be clouding your judgement? What biases do you have that are influencing your interpretation of this patient’s situation?

19. How do you continue to care for this patient in a family-centered way?

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