APPENDICITIS IN THE YOUNG CHILD. By Rebecca Lucas
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1 1 APPENDICITIS IN THE YOUNG CHILD By Rebecca Lucas
2 2 When time counts the most
3 Patient Profile 3 The patient 3 years old 2 months girl Usually is vibrant, articulate, incorrigible enjoys telling me how to do my job She has been sick for 53 hours with gastro sx Today is Monday She is lying in her dad s lap not speaking
4 Background Information 4 History Chief Complaint She says her tummy hurts History of Present Illness Vomiting started at 3am Saturday morning Mom hydrated with Gatorade Poor Food intake
5 Background Information 5 Past Medical History Product of a 33 week pregnancy Birth wt 3 lbs and 14 oz Regained average weight by 9 months Family History Father has sever allergies Social History She is in MDO 3 d/w Parents are both educators GM cares for her during the day Has had issues with health care provider anxiety
6 Physical Exam 6 Vital Signs: Temp 99.0 Ax Recheck ax, HR 109, RR 18, B/P 98/60 General: weak and pale complexion Skin: Hot and dry HEENT: nasal congestion with clear mucous, injected pharynx, TM s are clear Neck: Supple, no lymphadenopathy or masses. No JVD Chest: Lung fields CTA, no retractions Wt: 29 inches BMI: Heart: S 1 S 2 no murmurs Ht: 36 pounds Abdomen: firm, tender, bowel sounds mildly hyperactive, no hepatosplenomegaly. Genitalia: deferred Extremities: Cool, pale, with palpable peripheral pulses. Capillary refill is 6 seconds Neuro: Intact, WNL
7 Discussion of Findings-WGA 7 Vomiting and loose stools Abdominal Pain in a Young Child New onset fever Mild dehydration Nasal congestion and mild pharyngitis
8 Diagnostic Tests 8 Red Pharynx Strep Pharyngitis Influenza type a and b Clear Nasal Congestion
9 Appendicitis Score Lintula, Kokki, Kettunen, and Eskelinen (2008) 9 Criterion Score Gender Male (2 points) Female (0 points) Intensity of pain severe (2 points) mild /moderate (0 points) Relocation of pain Yes (4 points) No (0 points) Pain in RLQ Yes (4 points) No (0 points) Vomiting Yes (2 points) No (0 Points) Body Temp 37.5 C (3 points) < 37.5 C (0 points) Guarding Yes (4 points) No (0 points) Bowel Sounds Absent, tinkling, or high-pitched (4 points) Normal (0 points) Rebound Tenderness Yes (7 points) No (0 points) Total
10 This Patient 10 Criterion Score Gender Male (2 points) Female (0 points) 0 Intensity of pain severe (2 points) mild /moderate (0 points) 2 Relocation of pain Yes (4 points) No (0 points) 4 Pain in RLQ Yes (4 points) No (0 points) 0 Vomiting Yes (2 points) No (0 Points) 2 Body Temp 37.5 C (3 points) < 37.5 C (0 points) 3 Guarding Yes (4 points) No (0 points) 4 Bowel Sounds Absent, tinkling, or highpitched (4 points) Normal (0 points) 4 Rebound Tenderness Yes (7 points) No (0 points) 7 21 points corresponded with high probability for acute appendicitis 15 points the probability of acute appendicitis is low Total 24
11 Differential Diagnosis 11 Appendicitis with perforation Sepsis Gastroenteritis Mesenteric adenitis Constipation Urinary Tract Infection Intussusception Ovarian cyst or torsion Malrotation of bowel
12 Tests (the next step) 12 Complete Blood Count Elevated white count > 20,000 CAT scan versus US US-Inconclusive CAT with contrast-positive for enlarged appendix
13 System analysis 13 Primary care-rural site Timeliness for Lab and diagnostic studies Need to have Surgery available
14 Question 1 14 What absent symptom would give a greater chance of ruling out Intussusception?
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25 Question 2 25 What considerations should be taken next time this child is sick, especially with any stomach issues?
26 26 THE END
27 References 27 Behrman, R. E. (2003). Nelsons review of pediatrics. S.l.: Elsevier. Chan, M., Lee, N., Chan, P., Leung, T., & Sung, J. (2009). Fecal detection of influenza A virus in patients with concurrent respiratory and gastrointestinal symptoms. Journal Of Clinical Virology: The Official Publication Of The Pan American Society For Clinical Virology, 45(3), Churchill, S., Villareale, N., Monaghan, T., Sharp, V., & Kieckhefer, G. (2010). Parents of children with special health care needs who have better coping skills have fewer depressive symptoms. Maternal And Child Health Journal, 14(1), Colletti, J., Brown, K., Sharieff, G., Barata, I., & Ishimine, P. (2010). The management of children with gastroenteritis and dehydration in the emergency department. The Journal Of Emergency Medicine, 38(5), DeGoff, W., Anderson, J. E., & Chen, T. (2010). Back Pain as the Only Presenting Symptom of Intussusception: A Case Report. Clinical Pediatrics, 49(1), doi: / Goldman, R., Carter, S., Stephens, D., Antoon, R., Mounstephen, W., & Langer, J. (2008). Prospective validation of the pediatric appendicitis score. The Journal Of Pediatrics, 153(2), Marjanović, Z., Spasić, Z., Zivanović, D., Kostić, A., Djordjević, I., & Zdravković, D. (2006). [Acute appendicitis in the first three years of life]. Srpski Arhiv Za Celokupno Lekarstvo, 134(5-6), McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis for disease in adults and children. St. Louis, Mo: Elsevier Mosby. McCollough, M., & Sharieff, G. (2006). Abdominal pain in children. Pediatric Clinics of North America, 53(1), Zitelli, B. J., & Davis, H. W. (2007). Atlas of pediatric physical diagnosis. Philadelphia: Mosby/Elsevier.
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