Whirlwind on the wards

Started the wards today- seeing a ton of crazy stuff. Everything from TB pericarditis to a baby born with no eyes. I have a ton of learning to do, fortunately my residents are really good at getting things done. I also cover all the newborns, and fortunately they seem to be doing well. The triplets were all born overnight because mom had cord prolapse and they are all doing really well. The 32 weeker is almost at full feeds. Selfishly, today I am going to post my ward list that I made to keep track of the patients on my unit. My non-medical people out there will probably find it a bit boring, but I am welcoming feedback/recs/advice from any residents, etc in regards to my plans, workup. Remember, I am pretty alone here. I will spare you all the baby with no eyes, as it is pretty graphic and sad.

Bed 1: “Favour”

2.5yoM presenting with 1 week history of swelling of R humerus, L ulna, R tibia, L tibia. X-Ray shows chronic osteomyelitis. Ultrasound showed collection of pus of L tibia and R humerus, now s/p I&D. No fever, sickle negative, s/p transfusion x1 for low Hgb.

Plan: Continue Cloxacillin and dressing changes BID. Sedation with ketamine for dressing changes.

Bed 2: “Hope”

1mosF with spina bifida, hydrocephalus, and club feet. S/p myelomeningocele repair. Also with bacterial meningitis, s/p 14 days of Amp and Gent. CSF 5 days ago still with signs of meningitis. HC increasing but surgeons won’t place shunt until infection clears. Yesterday with signs of increased ICP and vomiting.

Plan: Repeat LP today, assess for WBC. If clear, talk to surgeons. Follow up HC, continue on Clox. PT to continue with casting for clubfeet.

Bed 3: “Jemina”

9mosF with R humerus swelling x2 weeks, found to have fracture x2, concern for rhabdomyosarcoma or osteosarcoma. CBC WNL.

Plan: Continue Clox, Biopsy of humerus to be performed tomorrow.

Bed 4: “Merciful”

15mosF presenting with 2 days of fever, decreased appetite, vomiting. Hgb 6.2 at that time, transfused 300cc whole blood. Sickle screen positive, will send for electrophoresis today. Malaria negative, BMP ok. Continued on Ceftriaxone and Ampicillin.

Plan: Continue Ceftriaxone and Amp. Send for blood for electrophoresis. Repeat Hgb now.

Bed 5: “Shanel”

2yoF with FTT. Birth weight 3.5kg, today 8.5kg. Started on F-100 regimen. Stool with no O&P, UA WNL. CBC showed Hgb of 6 (MCV 83).

Plan: Malnutrition protocol with mebendazole, folic acid, Vit A, and Zinc. Daily weights. Transfuse 100cc whole blood now. Sickle status?

Bed 6: “Ciemon”

2wkM presenting with fever, irritability, and jaundice. LP WNL. Today is day 5 of Amp/Gent. Bili on admission 20.3, repeat 3 days ago was 14.7 (14.7/1.7).

Plan: Repeat bili today. If decreased, turn off phototherapy. Repeat tomorrow with Hgb. Follow up weight today. Continue Amp/Gent

Bed 7: “Praise”

7mosF with cough, fever, poor feeding, diarrhea, and malaise for 3 days. Weight loss 1.6kg. Irritable. Flat fontanelle. Stool with WBC, malaria neg. CBC WNL. Started on Amp.

Plan: Continue on Amp, monitor fever curve. Send UA. (find otoscope?). If continues to be irritable will perform LP.

Bed 8:

2yoM with bilaterally nephroblastoma, finished chemo 4 days ago, planned for nephrectomy in 3 days. Spiked fever, ANC 530, started on Ceftriaxone. Now afebrile.

Plan: Repeat ANC now and if >500 will allow him to go home and return in 3 days. Will send home on abx if discharged.

Bed 9: “Princess”

2 day old female born at home, found to have bulging membranes from both eye sockets. Does not appear to have eyes.

Plan: Retinoblastoma? Anophthalmos? Look this up. Wet sterile gauze to membranes. Speak with Ophtho.

Bed 10: “Adele” 4yo with IBD? Getting better on antispasmotics. Plan: D/c home today.

Bed 11: Bacterial pneumonia, off O2. Plan: D/c home today.

Bed 12: New patient. 10yo with constrictive TB pericarditis. Re-presenting today for increasing abdominal girth, distention. No respiratory complaints. Need to see patient tonight.

*Bed 13: “Derrik”

10yoM who fell onto left hips 2wks ago when playing outside. Mom took him to traditional healer. Wound up with L leg DVT, confirmed on Doppler. Also with large abscesses on L wrist, R thigh, now s/p I&D. On exam with bilateral 2+ pitting LE extremity edema, significant increased work of breathing (93% on O2, 86% RA), chest pain, significant skin breakdown (SSS?). ECHO shows mild pericardial effusion, no tamponade, EF 70%. CXR with cardiomegaly and bilateral pleural effusions. Started on lovenox à warfarin, paused for high INR. Repeat today 1.83, will re-start Coumadin today. No IV access.

Plan: Resume warfarin. Repeat INR with next CBC. Start Lasix 40mg PO BID. Continue clox, flagyl, ibuprofen, PPI. Think about this kid a lot.

*Bed 14:

14yoM admitted yesterday for increasing abdominal distention and LE swelling x3 months. Also with anorexia, watery diarrhea, night sweats, muscle wasting. Paracentesis done at outside hospital and was told he had liver cancer. On exam is cachectic, with significant abdominal distension and significant hepatosplenomegaly, as well as multiple palpated irregular masses. 2+ pitting pedal edema bilaterally. L leg >R leg. Abdominal ultrasound shows bilateral echogenic kidneys, bilateral pleural effusions, mild ascites, hepatosplenolmegaly (homogenous liver?), and multiple hypoechoic antra-abdominal masses. CBC WNL. Na 120, ALT/AST 23/39. HIV neg, malaria neg. Albumin 1.6.

Plan: Send UA, stool. Doppler US of L leg. Tomorrow will do ultrasound guided FNA of abdominal mass, as well as obtain ascetic fluid- will save sample for pathology and send the rest for TB testing. See is mom can bring path to Bamenda. Discuss with nutritionist what to do for low albumin.

*BED 17: “Junior”

11yoM with L leg DVT in left common femoral. Also with cellulitis and pulmonary embolism. ECHO shows severe pulmonary hypertension and “strands” on tricuspid valves, as well as tricuspid regurg. Started on Lovenoxàwarfarin. Held for high INR. On Clinda, clox, ceftriaxone. Lots of chest and leg pain- on paracetamol, NSAIDs. O2 93% on facemask. Hemoptysis x1 today. CBC WNL. HIV negative.

Plan: Restart warfarin if INR is okay. Continue antibiotics, Follow up CXR.

BED 18: “Rudolf”

15yoM with multiple abscess- L thigh, L wrist, R thigh, R paraspinal- s/p multiple I&D (although not on back). Fever trending down on Clinda, Ceftriaxone, clox. Also with PNA.

Plan: BID dressing changes, sedate with Ketamine. Thoracic x-ray.

BED 20: “Ngen”

1.5yoM presenting with stridor, found to have large retropharyngeal abscess, now s/p I&D. Afebrile. Received decadron x2.

Plan: Continue amoxicillin, nebulized epi prn. Follow up with ENT.