Surgery

New York Presbyterian Queens

3/18-4/19/2019

History

Identifying Data:

Full Name: Z.L.

Address: Flushing, NYC

Date of Birth: 5/26/14

Date & Time: March 25, 2019 8:15 am

Location: NYPQ, Flushing, NY

Religion: N/A

Source of Information: Father, Translator services, and medical records

Source of Referral: Self

Mode of Transport: EMS

Chief Complaint: “Stomach hurts” x 1 day

History of Present Illness:

Z.L. is a Mandarin speaking 4 y/o male who presented to ED 2 days ago c/o abdominal pain x 1 day. Mid-abdominal pain began 2 hours after breakfast yesterday. Yesterday, mid-abdominal pain was dull, constant and rated 5/10 on pain scale without radiation or relieving factors. Pain shortly followed by episode of vomiting and brown, formed bowel movement which did nothing to relieve his pain. Vomit was nonbilious and did not contain blood. Z.L. went to bed without dinner. In the a.m., pain moved to RLQ made worse by walking, coughing, or moving rated 9/10 on pain scale without radiation or alleviating factors. Walking/moving aggravated pain. At this time, patient had subjective fever of ~100F per father. Patient also had 6+ episodes of non-bilious/non-bloody vomiting and 7+ episodes of non-bloody diarrhea since this morning and not tolerating medicine. Parents called EMS at this time because Z.L. would not walk due to pain. Upon presentation to ED, patient’s fever was 37.9. Sister recently had a cold but denies other sick contacts or travel. Denies HA, generalized weakness, fatigue, chills, night sweats, hematochezia, hematemesis, weight loss/gain, constipation, testicular pain, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. Denies urinary frequency or urgency, nycturia , oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Past Medical History:

Present illnesses – N/A

Past medical illnesses –N/A

Childhood illnesses – N/A

Immunizations – Up to date; flu vaccine yearly.

Screening tests and results) – N/A.

Past Surgical History: N/A.

Denies past injuries or transfusions.

Medications: N/A.

Allergies: NKDA. Denies other drug, environmental or food allergies.

Family History:

Mother – Alive and Well age 36

Father – Alive and Well age 40, HTN

Denies family history of cancer, DM, HLD

Social History:

Z.L. is a 4 y/o Mandarin speaking male living with both his parents in Flushing. He has no pets.

Habits – No drug, alcohol, or caffeine use.

Travel – Denied recent travel.

Diet – He eats well-balanced diet with many fruits/veggies.

Exercise – He goes on a daily walk with his mother x 1 mile in the a.m. He sleeps well about

8-10 hours each night.

Safety measures – Admits to wearing a seat belt and helmet when on bicycle.

Sexual Hx – He is not sexually active. Denies history of sexually transmitted diseases.

Review of Systems:

General – See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations,

pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headaches, vertigo or head trauma.

Eyes – Denies lacrimation, other visual disturbances, glasses use, or photophobia.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam was 3 months ago.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system –Denies palpitations, HTN, Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – See HPI.

Genitourinary system – See HPI.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical General: 4 y/o lying down NAD. Looks apparent age, well-developed and is well-groomed. AAO x 3.

Vital Signs: BP: R L

Seated 101/44 99/47

Supine 98/49 99/49

R: 20/min unlabored P: 84, regular

T: 36.3 degrees F (oral) O2 Sat: 97% Room air

Height 41 inches Weight 20 kg. BMI: 18.4

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: average quantity and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non tender to palpation throughout

Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;

conjunctiva & cornea clear. Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).

Visual fields full OU. PERRLA , EOMs full with no nystagmus Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No evidence of foreign bodies.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to

palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable

adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

THORAX & LUNGS:

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.

Breasts: symmetric, no dimpling, no masses, nipples without discharge. No axillary nodes palpable

Abdomen: Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations.

Hypoactive BS in RLQ and RUQ. No bruits noted over aortic/renal/iliac/femoral arteries.

Tender to percussion and palpation in all 4 quadrants. No evidence of organomegaly. No masses noted. Positive for voluntary guarding in RLQ and rebound tenderness in LLQ. No CVAT noted bilaterally.

Genitourinary: No rashes, ulcers, scars, nodules, indurations, discharge, scrotal masses, or hernias.

Rectal exam: Sphincter tone intact without masses or occult blood.

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Neurological: Mental Status

Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally(5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative.

Sensory

Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally.

Reflexes R L R L

Brachioradialis 2+ 2+ Patellar2+ 2+

Triceps 2+ 2+ Achilles2+ 2+

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

Labs:

Sodium: 142 (normal)

Potassium: 4.0 (normal)

Chloride: 104 (normal)

BUN: 20.0 (high)

Bicarbonate: 20 (low)

Creatinine: 0.32 (low)

Glucose: 111 (normal)

Calcium: 9.9 (normal)

WBC: 14.68 (high)

Hb: 12.3 (lowl)

MCV 76 (normal)

Hct: 38.3 (low)

Plt 450 (normal)

Diff Neutrophil 82 (high)

Diff Neutrophil Bands 8 (high)

Diff Lymphocytes 4 (low)

Diff Monocytes 4 (normal)

Diff Eo 1 (normal)

Protein 7.3 (normal)

Albumin 5 (normal)

Bilirubin 0.2 (normal)

Alk Phos: 174 (high)

Lipase: 27 (normal)

AST: 44 (normal)

CRP: 5.05 (high)

UA: yellow, sg 1.031 (high), pH 5.0, glu, protein, ketones, blood, nitration, leukocyte esterase (-)

US ABD: No definitive abnormality. No appendicitis evident on this exam.

CT ABD/Bowel/Mesentery with oral contrast: The colon and rectum are mildly distended with liquefied stool contents. Oral contrast present in ileum but not progressed to colon limiting the assessment of appendicitis. Appendix seen in RLQ taking a superior medial course with mild appendiceal wall thickening. Tip of appendix to right of the abdominal aorta is mildly dilated up to 8-9 mm with minimal inflammatory changes.

Assessment: 4 y/o male presents to NYPQ Surgery for laparoscopic appendectomy following laboratory and CT diagnosis of acute appendicitis.

Plan:

1. Acute Appendicitis +/- peritonitis- most likely due to patient presentation of eating, then nausea and vomiting, fevers and movement of right quadrant pain along with CT ABD findings. Discuss risks/benefits of surgical intervention with family members. Peritonitis likely d/t severity of pain and high WBC and pain exacerbated with movement.

a. Admit to floor

i. IVF- NS 1000 mL bolus

ii. PPX abx- Zosyn 80 mg/kg IV q 6 H

b. Patient NPO

c. Type and Screen

d. Strict I/O

e. Pain control

1. Children’s Tylenol 300 mg PO (if can tolerate otherwise IV) PRN

2. IV Ranitidine 39 mg PRN for nausea/emesis ppx

f. OR for laparoscopic appendectomy

D/DX:

1. Acute appendicitis- most likely due to bandemia and high CRP along with CT showing dilated appendix.

2. Viral Gastroenteritis- possible due to initial fever, vomiting, diarrhea and anorexia, but unlikely due to extreme pain patient is in along with CT findings suggesting appendicitis

3. Cholecystitis- unlikely d/t negative findings on CT ABD.

4. UTI- unlikely, UA is (-) for UTI and s/sx do not point to this etiology.

5. Testicular torsion- unlikely d/t (-) PE s/sx