Case (21)

[drmaxamed]

A 3 YEAR OLD BABY WAS ADMITTED TO HOSPITAL AT 4PM AND HAS 3 DAY HISTORY OF ACUTE ABDOMINAL PAIN AND VOMITING.
PAIN WAS SHARP IN TYPE AND INITIALLY STARTS UMBLICAL WHILE LATER RADIATES IN RIGHT ILIAC FOSSA AND ASSOCIATED WITH VOMITING WITH BLOOD , AND LATER BILE STAINED AFTER HOURS DISTENSION DEVELOPS AND PATIENT GET WORSE THAN BEFORE.
PAST HISTORY IS NILL EXCEPT WORMS TREATED BEFORE YEAR
REVIEW OF SYSTEMS IS NILL EXCEPT FEVER AND COUGH PRODUCTIVE
FAMILY HISTORY OF SAME SIBLING IS NOTED AND DIED , FATHER IS WELL AND HBSAG +  WHILE MUM IS HEALTHY
DRUG HISTORY DENIED NO ALLERGY NOTED

ON EXAM SHE IS PYREXIC .DRY TONGUE AND SUNKEN EYES  IRRITIABILITY, TACHYCAPNEA AND TACHYCARDIA
RR=38 AND HR=130 WHILE TEMP IS 38.7C SHE IS ALERT MENTALLY AND
ABDO EXAM IS TENDERNESS IN RIF AND MASS , NO ORGANOMEGALLY NOTED
RESP IS NORMAL SOUNDS AND HEART S1 AND S2 NOTED NO MURMURS AND OTHER SOUNDS
NEUROLOGIC EXAM IS OKEY

CBC SEND AND WBC 26.000 INCREASED
HB 8
ULTRASOUND APPENDICULAR MASS IN RIF NOTED

SHE IS NPO AND IV FLUIDS AND ANTIBIOTICS STARTED THEN DISTENSION DISAPPEARED

WHAT IS YOUR DIAGNOSIS ?
WHAT IS FURTHER INVESTIAGATIONS?

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[Dr.Hersi]

Diagnosis:
appendicitis complicated to appendicular mass (abcess)
further investigations:
1-Serum electrolytes
2-Urinalysis: to  detects red blood cells ,white blood cells and bacteria in the urine, sugar and proteins ,
3-Abdominal X-Ray :An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.
4--Computerized tomography (CT) Scan :CT Scan of the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal abscesses
5-Laparoscopy

[Admin]

I agree with Dr.Hersi because acute abdominal pain started around the umblicus and radiated to the right iliac fossa, associated with vomiting are in favor of appendicitis.

Although you didn't mention if she had constipation or not, the stained bile vomitus goes with intestinal obstruction.

Vomiting blood (hematemesis) in this case ?

I think also the onset and duration of cough is important in this case, because it can be from simple pneumonia to tuberculosis which can cause intestinal obstruction then appendicitis through fecalith formation (as mentioned by dr.hersi).

The abdominal distension that disappeared with IV fluid treatment can be due to paralytic ileus (hypokalemia), because excessive vomiting may lead to electrolyte imbalance and the patient is already dehydrated (dry tongue and sunken eyes).

So if we assume that there was paralytic ileus then it can be a functional cause of intestinal obstruction especially if intestinal obstruction developed after appendicitis.
Regards
Dr.Mahdi

[Admin]

This case is locked and the 15 points goes to Dr.Hersi