History of Present Illness:
The patient is a year old with failure to thrive
The patient is expected to need help with nutritional support
PEG has been recommended
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Past Medical History
Social History -
Home Medication - Reviewed
Allergies - Reivewed
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REVIEW OF SYSTEMS:
GENERAL: Pt is weak, requires continual support
HEENT: No gross abnormality
Eyes: No gross abnormality
Ears: No gross abnormality
Nose: No gross abnormality
Throat: No gross abnormality
LUNGS: no acute distress
CARDIAC: No chest pain. Rate and Rhythms are monitored
GI: Nausea. No vomiting. No diarrhea. NO Abdominal pain. No vomiting blood. No rectal bleeding.
GU: No frequency. No hesitancy. No hematuria. No pyuria. Pt has urinary catheter and output is
being monitored
NEUROLOGIC: limited
MUSCULOSKELETAL: when off of sedation, pt has full ROM.
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Vitals:
Physical Examination
GA: comfortable, no distress
HEENT: Atraumatic; normo-cephalic;
Eyes: EOMI, PERRLA
Nose: Nares patent, no sign of bleeding
Throat: Mouth is clear and no adenopathy, no deviation
NECK: Supple, no adenopathy, and no thyromegaly
LUNGS: No rhonchi, no wheezing. Bilateral
CHEST: Symmetrical excursion
CARDIAC: Regular, rate, & rhythm
ABDOMEN: +BS, Soft, Non-distended, No obvious organomegaly, and no obvious masses
EXTREMITIES: No cyanosis, No clubbing, No edema
SKIN: No lesions
NEURO: limited
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Imaging:
I have personally reviewed the imaging studies
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Labs:
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Assessments and Plans:
DX:
Failure to Thrive
Malnutrition
Failed Swallow Eval
The patient is a
who has failure to thrive
and needs prolonged enteral nutrition.
The patient would benefit from PEG placement
Risks and benefits of procedure was discussed with Family/POA
risks can be but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma,
injury to other organs, or need for further procedures or workup.
Other Complications may include deep vein thrombosis(blood clots),
as well as other side effects affecting other organ systems such as the heart or lungs,
and in rare circumstances, death as a result of the above complications.
The family and POA understands and agrees to proceed with the PEG placement