BS 9 y/o boy with Abdominal Pain

9 y/o boy with 5/7 hx D & V assoc with lower abdominal pain. 9 y/o boy with 5/7 hx D & V assoc with lower abdominal pain. Anorexia 5/7, tolerating fluids Anorexia 5/7, tolerating fluids Nil blood or mucous in stool Nil blood or mucous in stool Mild fever Mild fever Lower abdo pain mostly RIF initially. Given buscopan and paracetamol by GP – no improvement. Lower abdo pain mostly RIF initially. Given buscopan and paracetamol by GP – no improvement. C/- abdo pain with bumps on the car ride C/- abdo pain with bumps on the car ride History

Exam T 37.4 P91 R24 BP105/48 99% on RA T 37.4 P91 R24 BP105/48 99% on RA Dehydrated Dehydrated Holding abdomen, avoiding movement Holding abdomen, avoiding movement CVS, Resp, Testes NAD CVS, Resp, Testes NAD Abdo: Abdo: –Soft, very tender –Rebound tenderness ++ in LIF and RIF (worst in LIF) –Nil masses –Unable to mobilise to examine hop due to pain –Unable to cough due to pain

Ix WTU WTU –Glu neg; Ket 15mg/dL; Blo Trace; pH 5.5; Pro 100mg/dL; Nit neg, Leu neg Bloods Bloods Na K+ 3.4 Cl- 88 HCO3- 22 AG 16 Glu 4.9 Urea 25.9 Creat 132 CRP 349 Hb 131 WCC 25.1 Neut 22.15

DDx Gastroenteritis Gastroenteritis Appendicitis Appendicitis Meckel’s Meckel’s Mesenteric Adenitis Mesenteric Adenitis

Alvarado Score FeatureScore Migration of pain 1 Anorexia1 Nausea and vomiting 1 Tenderness in right lower quadrant 2 Rebound Tenderness 1 Temperature >37.5 °C 1 Leucocytosis2 Left Shift 1 Total10 8

Paediatric Appendicitis Score FeatureScore Fever >38 °C 1 Anorexia1 Nausea/Vomiting1 Cough/percussion/hopping tenderness 2 Right lower quadrant tenderness 2 Migration of pain 1 Leukocytosis >10 000(10 9 /l) 1 Polymorphonuclear-neutrophilia > 7500 (10 9 /l) 1 Total10 9

Mx Immediate laparotomy Immediate laparotomy Findings Appendix: small perforation, gangrenous and purulent Appendix: small perforation, gangrenous and purulent

New Paediatric Abdominal Pain Procedure 1. Initial Assessment by ED Dr History, exam History, exam Ward Test Urine – UTI, Diabetes, Pregnancy Ward Test Urine – UTI, Diabetes, Pregnancy Pathology – FBC, CRP (During lab hours – 0700 to 2400) Pathology – FBC, CRP (During lab hours – 0700 to 2400) Clinically rule out pneumonia Clinically rule out pneumonia –CXR if necessary (During Radiology hours 0800 to 2200) 2. Paediatric Dr to review Initial Alvarado and PAS scores Initial Alvarado and PAS scores AlvaradoPASAction ≥7≥6 Contact surgeons. ? OT Contact surgeons. ? OT Consider USS asap in routine hours Consider USS asap in routine hours Rpt score 4-8 hours Rpt score 4-8 hours <5<5 Admit, observe and rescore or review as OP in ~12 hours (?ward review clinic) Admit, observe and rescore or review as OP in ~12 hours (?ward review clinic) 3. After Hours ED Dr to follow as above and notify paed’s Dr on call.