Primary Care Case Presentation

Abigaille Chua, Paulo Pulanco

November 16, 2020
 Identifying Data
• 6/F
• Gradeschool student
• From Parañaque city
• CC: abdominal pain
 History of Present Illness
• 6 days of abdominal pain
• Epigastric -> RUQ, pervasive and non-
remitting
• (+) 3 episodes of non-bilous, non-bloody
vomiting (~90-175mL)
• (+) undocumented fever
• (+) loss of appetite
 History of Present Illness
• (-) bowel changes, (-) urinary symptoms
• (-) triggering or relieving factor
• (-) trauma

• Consulted with a private pediatrician, given

ORS
 History of Present Illness
• Consulted with a private pediatrician, given
ORS
• Fever and vomiting have since resolved
• Persistence of abdominal pain prompted
consult at PGH
 Review of Systems
• (-) headache, (-) facial edema, (-) dizziness
• (-) cough, (-) colds, (-) dyspnea
• (-) chest pain
• (-) melena, (-) hematochezia, (-) dysuria, (+)
tea-colored urine
• (-) jaundice, (-) edema, (-) rashes, (-) easy-
bruisability, (-) calf-pain
 Past Medical History
• UTI at 2 and 3 years of age, treated with ORS
and an unrecalled antibiotic
• Pathologic jaundice requiring 1-month
confinement
• (-) allergies
• (-) asthma
 Family Medical History
• (-) similar symptoms within the household
members
• (-) allergies
• (-) asthma
 Birth and Maternal History
• Born to a 17 year old G1P0 via caesarean
section for CPD with noted pathologic
jaundice
 Nutritional History
• Exclusively breastfed until 1 year of age,
breastfeeding until 3 years of age
• Complimentary feeding introduced at 6
months of age
• Current diet is same as household members
 Immunization History
• Immunization care of local health center
 Developmental History
• At par with age
 Physical Examination
• 90/60 144 24 38.6 °C 97%
• 18.5 kg 105 cm z-score of 1
 Physical Examination
• Awake, alert, cooperative, decreased activity,
able to feed and drink on her own
• AS, PPC, non-sunken eyeball, non-cracked lips,
moist oral mucosa, (-) central cyanosis,
(-)CLADs
• ECE, CBS, (-) decreased breath sounds
• Adynamic precordium, tachycardic, regular
rhythm, no murmurs
 Physical Examination
• (-) visible mass, (-) abdominal distention (+)
guarding on the right quadrant,
(+) direct tenderness, (-) rebound tenderness, (-)
palpable masses, (-) hepatomegaly, (+)
costovertebral angle tenderness on the right,
NABS
• FEP, PNB, CRT <2 sec, (-) bruises, (-) petechiae, (-
)rashes, (-) jaundice, (-) pallor, (-) edema, good
skin turgor
• Normal external genitalia, no discharge
 Salient Features
• We have a 5-year-old female girl who has been
having abdominal pain for 6 days, with a history
of vomiting and no signs of dehydration.
 Salient Features
• We have a 5-year-old female girl who has been
having abdominal pain for 6 days, with a history
of vomiting and no signs of dehydration.
 Pit Stop 1
• What other important questions we should be
asking?
 Pit Stop 1
• What other important questions we should be
asking?
– Diet preceding abdominal pain, water source, classmates
with similar symptoms?
– Diagnosis of the jaundice at birth?
 Pit Stop 2
• What do we think she has? What other disease
processes should we investigate?
 Pit Stop 2
• What do we think she has? What other disease
processes should we investigate?
– Gastroenteritis?
– Appendicitis?
– Urinary tract infection?
Differential Diagnoses
Analysis

King BR. Acute abdominal pain. In:

Hoekelman RA. Primary pediatric care. 3d
ed. St. Louis: Mosby, 1997:188
Analysis
 Pit Stop 3
• What diagnostics could help us?
 Pit Stop 3
• What diagnostics could help us?
– Urine analysis
– Complete blood count
 Laboratories
• Urinalysis
– Epithelial Cells 0
– RBC 4
– WBC 101 ↑
– Bacteria 585 ↑
– Mucus Thread 246 ↑
 Laboratories
• CBC
WBC: 17.40 x10^9 cells/L ↑
– Neutrophil 0.78 ↑
– Lymphocyte 0.11 ↓
– Monocyte 0.11 ↑
– Eosinophil 0.0
– Basophil 0.0
Or vomiting

More than 37.5 °C

More than 10,000

More than 0.7

 Or vomiting

More than 37.5 °C

More than 10,000

More than 0.7

8/10
 Diagnosis
• Acute appendicitis
• Urinary tract infection
• No signs of dehydration
 Pit Stop 4
• How does her disease process come about?
 Pit Stop 4
• How does her disease process come about?

OBSTRUCTION
 Pediatric Appendicitis
• Most frequent condition leading to emergent
abdominal surgery in children
• Classic symptoms are often not present
• Delay in diagnosis is associated with rupture
and complications
– First 36 hours: 16%-36%
– 5% increase for every subsequent 12 hour period

How time affects the risk of rupture in appendicitis.

Bickell NA, Aufses AH Jr, Rojas M, Bodian C
J Am Coll Surg. 2006 Mar; 202(3):401-6.
 Pit Stop 5
• How can we help her?
 Management
• Diet
-NPO

• Fluids

- 18.5 kg ~ 1,425 ml/day ~ 59.375 ml/hr

 Management
• Refer to surgery for appendectomy
 Therapeutics
• Medication
– Cefoxitin 40mg/kg ~ 750 mg IV prior to OR
– Cefoxitin 750 mg IV q6 for 24 hours

– Shift to Oral Amoxicillin-Clavulanate 250 mg PO

q12 for 4 days thereafter

E.Coli remains the most common

pathogen in pediatric UTI. Cefoxitin is
already able to cover for this as well
 Therapeutics
• Medication
– Omeprazole 80 mg IV OD while on NPO
– Paracetamol 120 mg/5 ml syrup, 6 ml q4 as
needed for fever greater than 37.8 °C
 Management
• For emergent appendectomy
• Pain relievers
– Acetaminophen and NSAID
– Does not change the Alvarado score
 Management
• Open vs Laparoscopic
- no significant difference
Grid iron/ McBurney
incision and Modified
McBurneys (aka Lanz or
Langer’s line incision)
 Management
• Mortality
– Non-perforated: 0.8 per 1000
– Perforated: 5.1 per 1000

• Morbidity
– Post-operative wound infection: ~<5% to 20%
 Management
• To explain to the family the current diagnosis
and plans for their little girl
 Key to evaluation and treatment plan
• Relieve the patient’s pain and discomfort early
and consistently
• Communicate with the patient and family
about the plans
• Repeat the examination often
• Keep the patient for observation if a firm
diagnosis is not made
 Pit Stop 6
• Some Fun Facts
 UpToDate
Acute Appendicitis Clinical Screening
 UpToDate
Acute Appendicitis Clinical Screening

0-4 – Low (Observe)

5-8 – Intermediate (Admit)
9-12 – High (Surgery
 Diagnostics
– Right abdominal ultrasound
– X-ray not recommended – (Italian Journal of
Pediatrics, 2017)
Diagnostics
Key Recommendations for Practice
 References
• American Family Physician
• British Medical Central
• National Institute for Center of Excellence
• Italian Journal of Pediatrics
• Journal of Pediatric Pharmacology and
Therapeutics
 References
• Scandinavian Journal of Surgery
• International Surgery Journal
• Annals of Emergency Medicine
• International Surgery Journal