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

Total 24

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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