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Case of Salas, Wilkie

Case of Salas, Wilkie. Case Management. Patient Information. Salas, Wilkie 2 y.o./M W11B19 88 th Hospital Day Chief Complaint: Enlarging Head, inability to support upright posture and loss of neck control. History:. Chief Complaint:

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Case of Salas, Wilkie

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  1. Case of Salas, Wilkie Case Management

  2. Patient Information Salas, Wilkie 2 y.o./M W11B19 88th Hospital Day Chief Complaint: Enlarging Head, inability to support upright posture and loss of neck control

  3. History: • Chief Complaint: • 6 mos PTA: noted gradual enlargement of head (-) consults • 5 mos PTA: persistence and progression of symptoms  consult at local hospital: ultrasound revealed hydrocephalus, referred to PGH • 2 weeks PTA: consult at PGH-Pedia DOPS: CT scan revealed posterior fossa mass, advised admission (August 13, 2009)

  4. Review of Systems Past Medical History: (+) Neck abscess (2008) s/p incision & drainage (2008) Maternal History: Patient born full-term to a then G2P1 22 year-old mother via SVD in a hospital, (-) fetomaternal complications

  5. Assessment Posterior Fossa Tumor: Primitive Neuro-ectodermal Tumor VS Choroid Plexus Papilloma s/p shunt insertion Nosocomial pneumonia, resolved Nosocomal sepsis, resolved New-onset pneumonia, resolved s/p tracheostomy tube reinsertion (10/13/2009) Atelectasis

  6. Physical Examination

  7. Course in the Wards 08/13: Admitted for management of Posterior Fossa Tumor 08/13 – present: Multiple history of nosocomial sepsis s/p intubation s/p tracheostomy 09/’09: noted decreasing sensorium GCS 15  increased sleeping time  GCS8  GCS 6 10/13: s/p tracheostomy intubation 10/27: explanation of prognosis, signing of DNR, deferred from all surgical interventions 10/01: (+) episode of tachypnea, Mother verablized: “Parang ayaw ko yata na DNR siya”

  8. Hospice Referral • 10/19: Referred for Terminal Care • Disposition: • For discharge, on CPAP • Discharge pending acquisition of CPAP mask, O2 tank, etc.

  9. Patient Issues • (+) occasional Cough • (+) occasional fever • (-) pain, (-) discomfort

  10. Reception with Parents • Initially, met with good reception, (+) note of apprehension upon informing re: Hospice Referral • Mother provided needed information voluntarily • Suceeding meetings: avoidant attitude, increasing anxiety • Discordant behavior: Says their “OK” but facial expression & actuations show uneasiness • Shrugs off attention: “No need, we’re OK.” “I’ll talk to you later.”; “I already talked to the pedia…” • Cooperates to some extent when prodded • Father of patient warmer, treads on wife’s behavior

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