Chief Complaint: “My stomach hurts and I feel really nauseous” x 2 days
HPI: 12 y/o male patient with no PMH presents to Pediatric ED accompanied by his dad with abdominal pain and nausea which began 2 days ago. He states that his pain originally yesterday was in the periumbilical region but now is in the RLQ as well. Pt admits that the pain is worse when he walks and changes positions while laying down in bed. He describes the pain as dully and achy and rates the pain a 7/10. His father states that he has a decrease in appetite due to his nausea and hasn’t been eating normally since this began 2 days ago. His last meal was a peanut butter granola bar this morning 7:00 am and has been more nauseous since. Patient admits trying tylenol yesterday night with slight relief of symptoms. Denies any sick contacts or recent travel. Also denies fever, vomiting, diarrhea, SOB, chest pain, flank pain, headache, sore throat, or any urinary complaints.
PMH:
None.
Per patient: Up to date on all immunizations.
Past Hospitalizations:
None
Past Surgeries:
None
Medications:
Acetaminophen (Unknown dose or frequency) – last dose last night.
Allergies:
No known drug, food, environmental allergies.
Family History:
Mother – 34 y/o. Alive and well.
Father – 38 y/o. Alive and well.
Social History:
Mr. E.W lives with his parents in an apartment in Queens.
No smokers at home and no pets
Safety: Admits to using seat belt.
Schooling: Attends middle school.
Exercise: Plays basketball with his friends in the park.
Travel: Denies recent travel.
Diet: Admits to well balanced diet.
Review of Systems:
General: Admits to change of appetite. Denies chills, fatigue, or weakness.
Skin, hair, nails: Denies hair changes, any signs of discoloration, any new rashes, or any changes in skin.
Head: Denies headache, dizziness, any recent head trauma.
Eyes: Denies any changes in vision, blurry vision, or discharge.
Ears: Denies pain or discharge.
Nose/Sinuses: Denies nasal congestion, swelling, epistaxis, or sinus pressure.
Mouth/Throat: Denies sore throat, cough, or hoarseness
Neck: Denies swollen glands.
Pulmonary System: Denies SOB or wheezing. Denies DOE, hemoptysis or cyanosis.
Cardiovascular System: Denies chest pain, edema, or palpitations.
Gastrointestinal System: Admits to abdominal pain and nausea. Denies changes in stool, hemorrhoids, constipation, rectal bleeding. or diarrhea.
Genitourinary System: Denies urinary frequency, oliguria, nocturia, or incontinence.
Nervous: Denies changes in mental status.
Physical:
General: Appears stated age and A&O x3 but appears to be in acute distress holding his abdomen and crying during examination.
Vital Signs:
Temp: 98.5 degrees F Oral
BP: 110/78 Right arm sitting
HR: 94 BPM, regular rate and rhythm
RR: 18 breaths/minute, regular rhythm unlabored
O2 Sat: 100% on room air
WT: 118 lbs
Hair, Skin, Nails:
Hair: Average quantity and distribution. No signs of lice or dandruff.
Skin: Warm and moist, smooth texture, good turgor. No discoloration or scarring.
Nails: No clubbing, or signs of infection. Capillary refill <2 seconds in upper extremities.
Eyes: Symmetrical OU. Sclera white, cornea clear, conjunctiva pink. Pupils are equal, round, and reactive to light. EOMs intact with no nystagmus. No strabismus, exophthalmos or ptosis.
Ears:
External ears with no masses, lesions, or discharge. B/L TMs pearly gray, intact with light reflex in good position.
Nose: No signs of masses, lesions, deformities, or trauma. No signs of nasal congestion.
Mouth: Lips pink and moist with no cyanosis or lesions. Buccal mucosa, palate, and gingivae are pink and well hydrated. No masses or lesions. Normal dentition, with no signs of dental caries.
Throat: Uvula is midline and not deviated. No evidence of petechia on soft palate or uvula. No signs of exudates or erythema.
Neck: Trachea midline. No masses, lesions, scars, pulsations. Supple and nontender to palpation. No cervical lymphadenopathy. Thyroid non tender to palpation.
Lungs:
Clear to auscultation. Chest was symmetrical with no signs of labored breathing.
Heart:
Regular rate and rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4.
Abdomen:
Peri-umbilical tenderness to deep palpation and RLQ tenderness to light and deep palpation. Obturator sign positive as right hip is rotated internally. Abdomen flat and symmetric, non-distended, no masses, ecchymosis or striae noted. Bowel sounds normoactive in all four quadrants. No CVA tenderness.
Neuro: Alert and Oriented.
Differential Diagnosis:
- Appendicitis
- Gastroenteritis
- Nephrolithiasis
- Constipation
- Obstruction
Assessment:
12 y/o male patient with no PMH presenting with 2 days of abdominal pain and nausea. Physical exam significant for tenderness in peri-umbilical and RLQ region. Positive obturator sign. Will obtain labs and imaging to R/O appendicitis.
Labs:
CBC with differential – Expecting to see elevation in leukocytes for appendicitis
CMP – Checking to see if there is any electrolyte abnormalities that may need to be corrected.
Type and Screen – May need to go to OR for surgery if appendicitis.
Imaging:
Ultrasound: Transferred patient to Cohen’s hospital for ultrasound and further care.
Plan and Education:
- Antibiotics – Ceftriaxone and Metronidazole
- NPO and IV fluids – lactate ringers
- Acetaminophen for analgesia
- Educated patient on appendicitis and how it is common in children and is a surgical emergency.
- Educated patient to f/u after treatment with pediatrician.
