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Answer the questions in the end. Answers are based on the case study.
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Cardiac Case study for NPW #2
9 wk.o. female with known history of large perimembraneous VSD followed by cardiology, has been on
lasix and enalapril at home, presented due to worsening of cough, emesis, feed intolerance, and poor
weight gain.
Parent states that she has attended her appointments, had no missed doses, but has been have frequent spit
up and emesis, so not sure how much medicine she is able to take. There’s a sick contact with a cousin
who had URI symptoms. She has not have any fever, or diarrhea.
Review of Systems
Constitutional: no fevers, no night sweats, irritability, no weight loss, no change in appetite
Head: no trauma, no swelling
Eyes: no redness, no discharge
Ears: no discharge, no known hearing loss
Nose: no discharge, congestion, no nose bleeds
Mouth: no sores, no pain with feeding
Resp: cough, no wheezing, increased work of breathing, tachypnea
CV: known, murmurs, sweating with feeds
Abd: vomiting, no diarrhea, no constipation, no distension
MS: no joint swelling, no joint redness, no decreased movements
Neuro: no seizures, no change in activity level
GU: no change in frequency, no hematuria
Skin: no rashes, no bruising, no cyanosis
Heme: no easy bruising or difficulty stopping bleeding
BP 90/56 | Pulse 164 | Temp 98.1 °F (36.7 °C) (Temporal) | Resp 58 | Ht 55 cm (21.65″) | Wt 3.18 kg
(7 lb 0.2 oz) | HC 36 cm (14.17″) | SpO2 94% | BMI 10.51 kg/m²
General: very irritable, but consolable, awake and alert
HEENT: no dysmorphic features, mildly tachypneic, no significant increased work of breathing
Heart: murmur present and tachycardic
Chest: Clear
Respiratory: crackles on bases, mild retractions
Abdomen: no palpable masses, soft, nondistended and nontender
Neuro: moves all extremities and moves spontaneously
Extremities: warm, well perfused and pulses palpable
Laboratory/Diagnostic Data and Outside Records
Recent Labs
WBC 16.25*
RBC 3.57
HGB 10.2
HCT 30.7
PLT 563*
C-Reactive Protein
Date Value Ref Range Status
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