Pediatric ED Case Conference Presented by R1 謝岳哲

General Data Name: 溫XX Gender: Male Age: 4y3m/o BW: 16kg Chart No: 4380467

2006-02-19 20:53 Keelung ER Triage: 3級 檢傷記錄：病患主訴因腹痛 Vital signs: --BT: 35.4 --HR: 129 --RR: 20 --BP: 160/109

Chief Complaint Post-prandial abd pain was noted after 稀飯 today

Present Illness No diarrhea No fever Activity: good Last meal: decreased Watery drinking: OK Decreased urine output Vomiting and diarrhea 5 days ago with improved

Past History: Denied systemic disease Allergy: Nil Vaccination: as scheduled

Physical Examination Cons clear, E4V5M6 HEENT : No active lesion HEART : tachycardia without murmur CHEST : clear BS ABDOMEN : normoactive BS tenderness over epigastrium and periumbilicus EXT: free movable 小朋友抱在媽媽懷裡，不肯下來走

What else more do you want to know? What’s your impression?

More about the patient…… History: Location? Onset? Pattern? Radiation? Alleviating or aggravating factors? Associated symptoms? Nausea/vomiting? Diarrhea? Bloody? Mucus? Fever? Cough? Sore throat? Headache? Dysuria? Hematuria? Trauma? Previous surgery? Congenital disorder?

More about the patient…… PE Appearance: dehydration? Toxic? Abdomen: Percussion? Peritoneal signs? Mass? Pharyngeal erythema?exudate? Breath sound? Heart sound? Knocking pain? Jaundice? Skin rash? Petechiae?

Pediatric Assessment Triangle B: work of breathing Abnormal airway sounds Abnormal positioning Retractions Flaring A: appearance – “TICLS” T– Tone I– Interactiveness C– Consolability L – Look/Gaze S – Speech/Cry C:circultion Pallor, Mottling, Cyanosis

Differential diagnosis of abdominal pain (2~5Y/O) Common AGE UTI Trauma Appendicitis Pneumonia, asthma Viral syndromes Constipation Less Common Meckel’s diverticulum HSP Toxin Intussusceptions Nephrotic syndrome Cystic fibrosis Rare Incarcerated hernis HUS Neoplasm Hepatitis Myocarditis, pericarditis Inflammatory bowel disease Choledochal cyst DM porphyria Textbook of Pediatric Emergency Medicine 5th ED, Table50.1

Life-threatening causes of acute abdominal pain (2~5 Y/O) Trauma Intussusception Appendicitis Incarcerated hernia Meckel’s diverticulum Obstruction secondary to previous OP Peritonitis Extra-abdominal Toxic overdose HUS DKA Sepsis Myocarditis, pericarditis Textbook of Pediatric Emergency Medicine 5th ED, Table50.2

Evaluation of abdominal pain

ED initial impression Abdominal pain, r/o gastroenteritis

Initial Order CBC/DC, BUN, CRP, Sugar KUB IV with D5W run 60cc/hr

Any comment about the order?

很不幸的…小朋友在當時沒有抽到血……

Bilateral subphrenic free air, C/W bowel perforation

Pneumoperitoneum Football sign Double wall sign Triangle sign Hepatic-lucency sign Visible falciform ligament

Extraluminal air “triangle sign” 腸子看起來很立體 “double wall sign” Falciform ligament

Impression Hallow organ perforation, cause? Pan-peritonitis

Clinical course Consult GS Empirical Abx use Transfer to Linko for operation

Lab results Item Value (2/19) WBC 18.1 K/uL RBC 5.48 M/uL Hb 11.7 g/dL Hct 37.6% MCV 68.6 fL PLT 290 K/uL Segment 76% Lymphocyte 20% Monocyte 1% Eosinophil 3% Item Value (2/19) Sugar 91 Na 138 K 3.9 Cl 105

OP Note Date:2006/02/20 OP procedure: laparoscopic repair of perforated duodenal ulcer Ascites: 100cc turbid ascites Duodenal ulcer: perforation at 1st portion, near lesser curvature, size 0.3*0.3 cm; omental wrapping around the perfoation hole (+) no other lesion was found in the peritoneal cavity fibrin coating over the duodenum

Clinical Course Check gastrin level on 2/23: 30.8 (28-185) Ascites culture: negative Discharge on 2006-02-24

Final diagnosis Duodenal ulcer with perforation at 1st portion complicated with peritonitis s/p primary repair