1. Pediatric ED Case Conference
Presented by R1 謝岳哲

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

3. 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

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

5. 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

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

7. 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

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

9. 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?

10. 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?

11. 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

12. 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

13. 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

14. Evaluation of abdominal pain

16. ED initial impression
Abdominal pain,
r/o gastroenteritis

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

18. Any comment about the order?

19. 很不幸的…小朋友在當時沒有抽到血……

21. Bilateral subphrenic free air, C/W bowel perforation

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

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

27. Impression
Hallow organ perforation, cause?
Pan-peritonitis

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

30. 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

31. 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

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

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