appendicitis in the young childessentiavitae1.com/dnpportfolio11/rlucas/documents/3may...powerpoint...
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APPENDICITIS IN THE
YOUNG CHILD
By Rebecca Lucas5/3/2011
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When time counts the
most
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Patient Profile
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
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Background Information
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
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Background Information
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
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Physical Exam
Vital Signs: Temp 99.0 Ax Recheck
101.4 ax , HR 109 , RR 18 , B/P 98/60
Wt: 29 inches Ht: 36 pounds
BMI: 15.73
General: weak and pale complexion Heart: S1S2 no murmurs
Skin: Hot and dry Abdomen: firm, tender, bowel sounds
mildly hyperactive, no
hepatosplenomegaly.
HEENT: nasal congestion with clear mucous,
injected pharynx, TM’s are clear
Genitalia: deferred
Neck: Supple, no lymphadenopathy or
masses. No JVD
Extremities: Cool, pale, with palpable
peripheral pulses. Capillary refill is 6
seconds
Chest: Lung fields CTA, no retractions Neuro: Intact, WNL
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Discussion of Findings-WGA
Vomiting and loose stools
Abdominal Pain in a Young Child
New onset fever
Mild dehydration
Nasal congestion and mild pharyngitis
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Diagnostic Tests
Red Pharynx
Strep Pharyngitis
Influenza type a and b
Clear Nasal Congestion
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Appendicitis Score
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
Lintula, Kokki, Kettunen, and Eskelinen (2008)
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This Patient
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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 high-
pitched (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
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Differential Diagnosis
Appendicitis with perforation
Sepsis
Gastroenteritis
Mesenteric adenitis
Constipation
Urinary Tract Infection
Intussusception
Ovarian cyst or torsion
Malrotation of bowel
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Tests (the next step)
Complete Blood Count
Elevated white count > 20,000
CAT scan versus US
US-Inconclusive
CAT with contrast-Positive for enlarged appendix
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System analysis
Primary care-Rural site
Timeliness for Lab and diagnostic studies
Need to have Surgery available
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Question 1
What absent symptom would give a greater chance
of ruling out Intussusception?
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Question 2
What considerations should be taken next time this
child is sick, especially with any stomach issues?
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THE END
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References
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), 208-211.
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), 47-57.
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), 686-698.
DeGoff, W., Anderson, J. E., & Chen, T. (2010). Back Pain as the Only Presenting Symptom of Intussusception: A Case Report. Clinical Pediatrics, 49(1), 43-44. doi:10.1177/0009922809342461
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), 278-282.
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), 203-207.
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), 107-137.
Zitelli, B. J., & Davis, H. W. (2007). Atlas of pediatric physical diagnosis. Philadelphia: Mosby/Elsevier.
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