61475369 Nuts 317l Peds Clinical Judgment Plan

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Lusine Khechumyan
Clinical Judgement Plan
West Coast University
Professor Ronisha Johnson
Date
OB Version Feb 2022
PEDIATRICS Clinical Judgement Plan
Student Name:
DATE Care Provided and UNIT:
Patient Information
Patient Initials: JJ
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
Jasmin Jj, an 11-year-old female, was admitted due to recurrent epigastric pain that escalated to severe (10/10) pain with
food-colored emesis. She has a history of cholelithiasis (gallstones) and had undergone a cholecystectomy in April 2023.
Over the past few months, she experienced intermittent pain, often aggravated by greasy foods.
(1)
Age & Gender: 11 years, Female
Pathophysiology of Admitting Diagnosis (Gallstones):
Gallstones are solid deposits, mainly cholesterol or bilirubin, forming in the gallbladder (Nath, 2018). They can develop due
to imbalances in bile composition, reduced gallbladder motility, inflammation, and various risk factors.
Height/Weight:54 inches 80 pounds
Medical History:
Code Status: Full Code
Living Will/ DPOA: NA
Chief Complaint
Patient presents with severe epigastric pain
Pain has been ongoing for 10 days
Last night, pain acutely increased to 10/10
Admitted to the hospital due to severe pain
Admitting Diagnosis & Admission
Date
Gallstones
September ,10 2023
Gastritis: Inflammation of the stomach lining, likely aggravated by her diet and contributing to her symptoms.
Cholelithiasis ( …
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