‘CASE PROTOCOL ‘This isthe case of La nine year old male from lilo City, He came in witha chief complaint of abdominal pain. History of Present liness :L month PTA, the patient complained of abdominal pain of with a grade of 710. He was brought by his parents to.a physician. Laboratory exams were requested. Stool exam revealed Ascariasis and was prescribed with unrecalled medications with relief of abdominal pain. ' days PTA, he was noted to have abdominal enlargement. No consult was dane nor medication taken, No abdominal pain noted. (On the day of admission, he developed severe abdominal pain. He was brought to the hospital and was subsequently admitted. Past Medical History ‘The patient was admitted for intestinal amebiasis at year of age. Family History A history of malignancy was noted on the maternal side. Personal History He had unremarkable prenatal and maternal histories. Neonatal History He ras delivered full term by NSVD ina hospital Immunization History His immunizations are complete. Developmental Milestones He has normal developmental milestones Review of Systems Irritability and abdominal pain were present. Physical Examination: '¢ Vital signs: BP 10060; CR: 100beats/min; Temp: 36.5, ‘© Anthropometric measurement: Weight 24Kg © NoLymphadenopathies © Clear breath sounds ‘© Globular abdomen, Normoactive bowel sounds, (+) Abdominal distention; (+) right quadrant ‘mass approximately 8.5cmx 6cm, (+) tender abdomen ©The rest ofthe physical examination were unremarkable.(On the day of admission: ‘+ Laboratories were requested ‘+ Patient placed on NPO ‘+ Referred tothe Department of Surgery "Hospital Day: *Afebrile; table V/5;(-) abdominal pain, (+) ‘+ Harsh breath sounds; soft abdomen, (4) Palpable liver © Started with Ceftriaxone 2.5gm OD © Nebulization with Salbutamol qBhours © Requested Abdominal CT Scan, AFP, TPAG, APTT, Protime, SGPT, peripheral blood smear © 3:25PM, © 7383 © Paracetamol 250mg IVIT = 4:45PM, ‘© Given Vitamin K 10mg IVIT stat then OD x 2 more doses 2" HD ‘+ Stable W/S; Abdominal girth ~ 60cm; No complaints of abdominal pain (+) febrile episode ‘© Patient placed on General liquids 3% & 4" HD —Unremarkable 5S HD- in the early morning, he complained of LC.abdominal tenderness — given tramadol SOmg IV ‘© (18M; passed out fatus ‘+ Soft abdomen; afebrile 7° HO ~Tense abdomen #8” HD - Working Diagnosis: Pediatric Community Acquired pneumonia, Moderate Risk 9 HD ~for Exploratory Laparotomy 10° HO- 500m : RR: 30 ; (+) alar flaring, minimal subcostal retraction; (+) bipedal edema; (+) ascites Meds given: Furosemide 25mg ITT Plans: for UTZ guided thoracentesis; PPD; Sputum AFB. © 0/CCeftriaxone © Start Metronidazole 41" HD - Early morning ~ persistently Tachypnee, Transferred to PICU © Started on Ceftazedime and Oxacilin © Referred to pediatric gastroenterologist12" HD Early morning complained of Chest pain 7/10; VSBP 90/60, CR 89, 737.5, ‘© Paracetamol 250mg p.0. ‘© ECG-Sinus Tachycardia 730M, ‘No chest pain; Tachypnetc, (+) puffy eyelids, decreased breath sounds and vocal fremitus bilateral mid lobes, distended abdomen, smiling umbilicus, (+) fluid wave, (+) grade edema 930aM GCS-15, RR=30'5; (+) difieulty of breathing; 02 inhalation at 10L/min; BP ranges from 90-110/60-80 13" HD~(+) PPD started on HRZE ‘© Folks refused thoracentesis 15% HD ~ Afebrile; AR ranges from 20-82cpm; 02 sat 96-98%; lying comfortably; () DOB; (-) Chest pain; letericsclerze; (+) periorbital edema; SCE, HBS, decreased breath sound R>l; Latest abdominal girth ‘Tocms; decreasing bipedal edema; Intake - 1490ml; Output 147ml 16" HD for Gene Xpert; Hold anti TB meds ‘© May go home per folks request a7" HD- + 840- Patent prstertytachypnete (+1008; 8-205 + 1030-Refered for Hypotension © Appraised for iubation but refused © Folsrefused CPR and EMERGENCY MEDICATIONS + 1100-Proneunced Dead «Folks requested fran autopey Lasonaronies coc : Day Fr 7 [aa [Heo__}a22_|a34_fazz_t WBC | 15.03 | 11.10 | 11.70 oittct = Band oa [neuro 74 tympho oz ‘Adequate [AdeUrinalysis Specific gravity - 1.025 Ketone ~(+) Pus cells —3-5/hpt Protime ~62% © APTT=28.2 sec ‘© Serum Calcium ~2.28mmo/l ‘+ SerumK=3.85mmol/ © Serum Ni 4immol/t ‘© Serum Creatinine ~ 43.19 umol/L ‘© BUN- Normal © sePT-21u/t ‘© Protein-66.06g/. © Albumin ~32.67¢/L Globulin 34.4g/L AEP -<0.S01U/ml © NG ratio= 3g/t LUTZof the whole abdomen | Day + Stool Exam—No parasite seen © RBC-1-Yhof ‘+ Chest Xray — Negative for cardiopulmonary findings ‘+ Abdominal X-ray (Supine, Upright, Cross table lateral -No Localizng signs 1 i | Hepatomegaly with multiple hypoechoic nodules. Inflammatory vs. Neoplastic in nature Epigastrc lesion. Rule out Bowel in origin (intussusception) Minimal Ascites Cystitis with sediments Normal biliary tree, pancreas, spleen kidneys and prostate banatDay2 ABDOMINAL CT SCAN: GLNICAL NOTES: abana! tenon apn Fine & eave conas emrarced ual oneryap: scion cba sdoninal regan wer ce a TAS 8 mabe nnomogenouty rang maweserend et ean tn sara. rg of TESLA cd sipaumicaty ain mleter te Wr toppers septation a ara ot (Ritson cpa an vane: econ, wane oma 6 138394498 om LaVVAP), Te eae epoca ‘eapresees sme ol bowel aso eclocos od fates ha paceas pox Trae ered’ Somes nthe ek ‘poe quant wa, rarer hie ney. gen meses Sof Bon eh the ert Nett rae en cranceact pane 13. The be mia pode ae ath ep ben sah spe rare parton of he ih heel be mesttag 08x FSD 2 Yen AIHA) The elec sano powers 8627 Fone ‘The panos and toa pnd re nea Me ae sue Pemopeety No fea prechyalmss n Seren nt: nd ie tenet ct rg cece wn, ‘ne army are nsatsund anne 86ST IV Sob cy Cath Caner ar fmansing 808 3.118 305 (AMIN he igh hte messing 832 3.95 « 239.0n LatnAryn ie ch. No focal mane ence sen. The pewecaieal cre a fa ease act Ra ans "The winary adder has smooth and non chen wal. Noiiabmnnal ng delet ot extn ees wt The frost ot eaged nse ar tase Pomogencty ‘There erin fo witaperanes had elochon nos posthepee ad lve aes, {her is ema pur wd coecton biatraty Mary deste rv seen fhe baal tng lds The fest ole todas te weenahate REMARKS: ‘++ DIFFUSE INTRAPERITONEAL MASSES, PROUABLY MESENTERIC IN ORIGIN, AS DESCRIBED. IISTOFATHOLOGIC CORRELATION IS SUGGESTED FOR FURTIIE. EVALUATION \ TEPATOSPLENOMEGALY Wr PANIC NODULES, [MESENTERIC NODULES, LEFT UPPER QUADRANT AREA. MINIMAL ASCITES, INCIDENTAL FINDINGS OF BIBASAL PNEUMONIA AND MINIMAL BILATEAL PLEURAL J emsi0n Day7 © Protime = 78% ay10 «© Chest Xray - Pneumonia, Lower Lungs; Pleural Effusion with interfissural fluid collection, Right Day 11 « Protime ~64% © APTT~285 «© Serurn Creatinine ~71.71 # Albumin -27.71 ° ABs ‘0 pH-7.44; pCO2 -29 mmbg; p02 ~ 83; HCO3 ~ 22mmol/L; O92 inhalation at YLDay 12 '* Bleeding time -1 min '§ Clotting time -16 min ‘© Blood Culture ~No growth after 24 hours incubation Day13 ‘© Blood culture —No growth after 3 days incubation