Case 1. Case Discussion. History. Present Illness. Impression. Physical Examination
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1 Case 1 Case Discussion R1 林吉倡 2013 / 01 / yo Male BW: 45 kg DAY1 16:35 pm C/C: Epigastric pain since this morning TPR: 36.5/94/18 BP:133/83 SpO2: 100% GCS: 15 Triage: 2 Present Illness Sudden-onset (3-pm),sharp pain; radiation(-), postural related (-) Nausea (+), Vomitus (-), Diarrhea (+) [twice; mucoid/bloody(-)], Loss-of-appetite (+) [lunch(-)] NO fever/chillness, URI, trauma, dyspnea, cold-sweating History Medical Frequent constipation (infant elementary school); Daily defecation in recent 2 years Manometry (2004/06)- WNL of int. sphincter (12/19): AGE Surgical: DENIED Allergy: NIL Physical Examination Chest: Clear breathing sound Abdomen: Distended above umbilicus; Epigastric tenderness Hyperresonance-on-percussion No rebounding pain or muscle guarding Impression Acute gastroenteritis Ileus/ Bowel obstruction Extremities: Warm
2 Abdominal CT OP Finding Serous ascites: 100 ml Redundant sigmoid colon (20 cm) with 180- degrees rotation No ischemia or gangrenous change Discussion 40~70% of colonic volvulus Cecum > T-colon & splenic-flexure Elderly, institutionalized, debiliated (parkinsonism, schizophrenia) patients Colonic dysmotility Discussion RARE in young children or adolescent Delayed diagnosis due to atypical age Initial presentating feature of Hirschprung s disease J.Pediatr Surg. 1997;32(1):117
3 Complications of Hirschsprung Disease Acute intestinal obstruction (neonate) 95% failure to pass meconium Hirschsprung-associated enterocolitis (HAEC) Explosive foul-smelling diarrhea, fever, vomiting, abdominal pain and distension Enterocolitis Pre-, Immediate, and Post-operative Volvulus Radiographic Finding Proximal colon distension Cut-off sign" Pathogenesis Bacterial overgrowth in bowel-lumen Stasis & protective mucin (bifidobacteria and lactobacillus) pathogenic bacteria (C. difficile, S.aureus) IV-antibiotic Aerobic & anaerobic Rectal irrigation Treatment (Pre-OP) Diverting colostomy Case 2 1Y11M Male DAY1 C/C: Fever for one day
4 Present Illness Physical Examination Intense dry cough post-tussive vomiting meal-intolerance since 4-pm yesterday evening Fever up to 39 degrees around 11-pm DENIED rhinorrhea, GI-upsets, diarrhea, turbid urine, skin rashes 19 TPR: 37.7/158/30, BP:105/89, SpO 2 :95%(RA) HEENT : Injected throat Chest : right breathing sound No stridor or wheezing : No accessory muscle use or nasal flaring Abdomen: Soft and flat without tenderness 20 Tentative Diagnosis???? 21 Present Illness Preceding choking episodes Discussion Life-threatening emergency 1~3 years old mobility and oral exploration 23 24
5 Consider foreign body aspiration in a young child with respiratory symptoms, regardless of the duration Many children may present >24 hours after foreign body aspiration. Classical dogma Laryngotracheal: Stridor, hoarseness Bronchial: Unilateral wheezing Breath sounds History of sudden coughing and choking most predictive of all signs and symptoms Radiography 9Y, Male Radiographs are helpful to confirm the diagnosis of airway foreign body NOT to exclude the diagnosis, > 50% of tracheal foreign bodies ¼ of bronchial foreign bodies <NORMAL> > 75% of airway foreign bodies are radiolucent in children < 3-yo Radiography Indirect Signs Unilateral obstructive emphysema Check-valve obstruction Inspiratory-expiratory films: Air trapping Disposition at SKMH Consult ENT Transfer Atelectasis Consolidation 29
6 Case 3 8Y11M Male BW: 30 kg DAY1 09:24 pm C/C: Left side weakness since this morning TPR: 35.5/127/20 BP:127/75 SpO2: 99% GCS:E3V3M4 Triage: 2 Present Illness Sudden onset (? time) shouted abruptly Vomitus with left side weakness and consciousness-change DENIED trauma, seizure, drug history History Physical Examination Medical: Surgical: Allergy: NIL Autism DENIED Pupils: 3+ / 5+; Neck: Supple Chest: Clear breathing sound Abdomen: Soft, flat Muscle power R/L: 5/2 Babinski: Negative over left side Brain CT
7 Guillain-Barre Syndrome Preceeding URI or AGE (2~ 4 weeks) Acute, progressive, symmetric, ascending weakness (gait-difficulty) DTR or absent Neuropathic pain, but min. sensory loss Sensory dysfunction, ophthalmoplegia, ataxia & bulbar dysfunction (Miller-Fisher Syndrome
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QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?