Comprehensive Evaluation
Detailed patient history and physical evaluation are vital to making accurate medical judgments. Therefore, parents of pediatric children provide useful information that facilitates truthful diagnoses. This paper provides a comprehensive evaluation of a case study involving a child with abdominal pain.
Subjective Information
T.A., a 26-month-old male child with a medical history of Down syndrome and congestive heart failure, was brought to the hospital by his mother. T.A.’s mother reported that her son had abdominal discomfort for the past two days, which caused him to be lethargic, withdrawn, cranky, and a poor eater. Other symptoms presented by the child included vomiting, reduced urination, dark, strong-smelling urine, excessive sweating, and rapid breathing.
She denied head trauma but reported that the child sustained a big abdominal bruise following a fall while under the care of her boyfriend. T.A. had an asthmatic older brother aged 5 years and a younger healthy brother aged 6 months. The child’s mother was a single parent with a low income and a poor support system. Therefore, she could not afford daycare services and was forced to ask for help from her neighbors or boyfriend. She admitted that her boyfriend did not like taking care of the children.
Objective Information
The child was inactive, pale, and afebrile. He had a high pulse rate, tachycardia, hypotension, and tachypnea. The child’s height and weight were smaller than those of most children his age. T.A.’s skin had faded circumferential macular discolorations at the wrists, which was commonly seen in old ligature marks. The child had dental caries. A delayed capillary refill of 4 seconds showed probable dehydration, shock, and reduced renal perfusion (Fleming et al., 2015).
An abdominal examination indicated a firm, swollen abdomen with diffused sensitivity. The skin around the epigastrium was discolored due to bleeding attributed to bruising. A reducible 2 cm umbilical hernia was noted. The child had a diaper rash and weak muscular movement. A neurologic examination revealed a decreased level of consciousness. Laboratory tests indicated an elevated WBC count, lipase, amylase, lactic acid, and prothrombin levels.
The comprehensive metabolic panel’s findings were abnormal and consistent with electrolyte imbalance. An abdominal computed tomography (CT) showed significant bowel distention, edema, and blood collections, which are common in a duodenal hematoma. A chest and abdominal x-ray revealed an acute rib fracture of the left 8th rib, healing rib fractures of the right 4th and 5th ribs, and old rib fractures of the right 9th and 10th ribs.
Assessment
Four differential diagnoses were made: child abuse- acts of commission- (T76.12XA), duodenal hematoma from blunt abdominal trauma (K92.2), systemic inflammatory response syndrome (SIRS) (R65.1), and Hirschsprung’s disease. The final diagnosis was child abuse. This diagnosis was supported by the child’s height and weight, which pointed towards poor nutritional status. T.A.’s skin had faded circumferential macular discolorations at the wrists, which were common in old ligature marks. These marks were consistent with physical abuse by forceful physical restraint (Knox et al., 2014).
The presence of dental caries also showed neglected dental hygiene. In addition, the diaper rash was an indication of negligence in the day-to-day care of the child. The acute, healing, and old rib fractures were signs of consistent trauma to the rib area.
Plan
The treatment plan involved immediate resuscitation and stabilization, followed by an admission of the patient to the ICU. Specific measures included stabilizing and monitoring the vital signs (breathing pattern and pulse rate) through oxygen supplementation, continuous pulse oximetry, and cardiac monitoring. Fluid and electrolyte balance was restored through two large-bore IV lines (Lerman, Coté, & Steward, 2016). It was also necessary to establish enteral or parenteral nutritional support as required. The primary cause of the child abuse was addressed by relevant authorities, including child protective services, police, and social workers, to safeguard the wellbeing of the child.
Conclusion
Effective treatment involves the immediate restoration of normal body functions before addressing the cause of illness. In this case, it was necessary to reinstate the vital signs before seeking help from authorities to protect the child from further abuse.
References
Fleming, S., Gill, P., Jones, C., Taylor, J. A., Van den Bruel, A., Heneghan, C., & Thompson, M. (2015). Validity and reliability of measurement of capillary refill time in children: A systematic review. Archives of Disease in Childhood, 100(3), 239-249.
Knox, B. L., Starling, S. P., Feldman, K. W., Kellogg, N. D., Frasier, L. D., & Tiapula, S. L. (2014). Child torture as a form of child abuse. Journal of Child & Adolescent Trauma, 7(1), 37-49.
Lerman, J., Coté, C. J., & Steward, D. J. (2016). Manual of pediatric anesthesia. New York, NY: Springer.