Tommy Acker (TA) Patient Encounter
Tommy Acker (TA), a 26-month-old male with Down syndrome, presents with abdominal pain, poor appetite, and decreased level of activity x 2 days. PMH is significant for atrioventricular septal defect (complete), status-post surgical repair; congestive heart failure, resolved following surgery; and, global developmental delay.
His mother reports that the patient is “complaining” of abdominal pain with associated decreased oral intake and decreased activity for the last two days. All symptoms reportedly started soon after his “falling out of the bed during his nap.” There was no known head trauma; there was one episode of vomiting last night, but no diarrhea, constipation, or GI bleeding. Last bowel movement not recalled. The mother does note that TA has been somewhat lethargic, but “won’t stop whining”; his skin feels sweaty but not warm; his breathing has been more rapid; and, his urine is diminished in volume, dark in color, and strong smelling. She denies prior injuries requiring medical attention.
1. Evaluate lab results to determine the actual and/or potential diseases for which patient is at risk (SEE LAB RESULTS), PLEASE REFER TO UPLOADED GRADING CRITERIA AS WELL.
2. Explain history and physical assessment results that contribute to TA’s risk.
3. Cited lab results correlate with the assessment findings to help determine risk
|
Name |
Value |
Units |
Reference Range |
|
White blood cells (WBCs) |
19000 |
mm3 |
4,000-10,000 |
|
Red Blood Cell Count (RBC) |
4.5 |
million/µl |
4.5-5.9(♂), 4.0-5.2(♀), adults |
|
Hemoglobin (Hgb) |
9 |
g/dl |
14-18(♂), 12-16(♀), adults |
|
Hematocrit (Hct) |
27 |
% |
42-54(♂), 37-47(♀), adults |
|
Mean corpuscular volume (MCV) |
84 |
fl |
82-103, adults |
|
Mean corpuscular hemoglobin (MCH) |
27 |
µm3 |
26-34, adults |
|
Mean corpuscular hemoglobin concentration (MCHC) |
30 |
% |
30-37, adults |
|
Platelets (thrombocytes) |
80 |
k/dL |
150-399, adults |
|
Red cell distribution width (RDW) |
12.2 |
% |
11.5-14.5, adults |
|
Neutrophils |
81 |
% |
46-78, adult |
|
Lymphocytes |
17 |
% |
18-52, adult |
|
Monocytes |
1 |
% |
3-10, adult |
|
Eosinophils |
1 |
% |
0-6, adult |
|
Basophils |
0 |
% |
0-3, adult |
|
Segmented neutrophils |
77 |
% |
36-72, adult |
|
Band Cells |
4 |
% |
0-6, adult |
Interpretation: Abnormal CBC with differential. Discussion: The CBC is the most ordered test in medicine, yet it is very nonspecific. It can be helpful, however, when assessing for extreme out-of-range values (e.g., leukocytosis and leukopenia), as these values can guide resuscitation and/or certain treatments.
Example: Use of SIRS criteria for shock resuscitation in sepsis:
· Neutrophils help mediate anti-inflammatory activities in illness and have prognostic significance in shock.
· Hemoglobin and hematocrit assess for anemia and/or signs of blood loss.
· The platelet count provides information regarding the patient’s hemostatic risk for bleeding; a count may be an indicator or disseminated intravascular coagulation (DIC).
· Thrombocytosis (elevated platelet count) is frequently seen in Henoch-Schonlein purpura.
Beware of thought processes leading you to exclude certain diagnoses or surgical conditions because of a “normal” WBC count.
Comprehensive metabolic panel (CMP)
|
Name |
Value |
Units |
Reference Range |
|
Sodium (Na+) |
150 |
mmol/L |
135-145 |
|
Potassium (K+) |
6.0 |
mmol/L |
3.5 to 5.1 |
|
Calcium (Ca2+) |
7.0 |
mg/dL |
8.7-10.7(1 mo-adult), 8.7-11.9 |
|
Chloride (Cl-) |
90 |
mmol/L |
95-102(1mo-adult), 91-118(1d-1mo) |
|
Carbon dioxide, total (CO2) |
12 |
mmol/L |
22-29(15y-adult), 20-28(1y-15y) |
|
Glucose (BG/Glu) |
130 |
mg/dL |
70-110(fasting), 70-200(non-fasting) |
|
Urea nitrogen (BUN) |
45 |
mg/dL |
8-21(15y-adult), 5-18(1mo-15y) |
|
Creatinine |
2.0 |
mg/dL |
0.6-1.3(♂), 0.5-1.1(♀) |
|
Albumin |
2.5 |
g/dL |
3.5-5.0(adult), 2.9-5.5(0-3y) |
|
Bilirubin, total |
0.5 |
mg/dL |
0.2-1.3(1 mo-adult), 0.6-11.1(1d-1mo) |
|
Protein, total |
4.5 |
g/dL |
6.0-8.2(8y-adult), 5.6-8.5(1mo-8y) |
|
Alkaline phosphatase (ALP) |
25 |
units/L |
30-125(adult), 80-250(1d-15y) |
|
Aspartate transaminase (AST) |
13 |
units/L |
3-44 |
|
Alanine transaminase (ALT) |
11 |
units/L |
0-40 |
Interpretation: Abnormal CMP. Discussion: The CMP helps in assessment of electrolyte abnormalities, renal failure, dehydration, malnutrition, and other organ dysfunction. Rapid correction of electrolyte abnormalities and dehydration is often needed in shock resuscitation.
Lipase
|
Name |
Value |
Units |
Reference Range |
|
Lipase |
60 |
units/L |
10-52 |
Interpretation: Abnormal serum lipase. Discussion: Lipase is the more specific test for pancreatic injury or inflammation. It can also be used as a prognostic indicator.
Lactic acid, serum
|
Name |
Value |
Units |
Reference Range |
|
Venous blood |
|||
|
Arterial blood |
> 4 |
mmol/L |
< 2 mmol/L |
Interpretation: Abnormal serum lactic acid. Discussion: Elevated lactic acid (lactate) can be an early prognostic indicator in a patient with traumatic injury, including bowel injury or ischemia.
· Though a nonspecific test, the lactate level helps guide initial fluid resuscitation in a critically ill patient with suspected sepsis or blood loss.
· The therapeutic goal is to resuscitate to a normalized lactate level.
Venous blood gases (VBG)
|
Name |
Value |
Units |
Reference Range |
|
Venous pH |
7.2 |
7.33-7.43 |
|
|
PvCO2 |
mmHg |
41-54(♂), 38-51(♀) |
|
|
PvO2 |
< 65% |
mmHg |
25-29 |
|
Bicarbonate, venous (HCO3-) |
mEq/L |
22-29 |
|
|
Carbon dioxide, venous (CvO2) |
ml/dL |
11-15 |
|
|
Oxygen saturation, venous (SvO2) |
% |
60-85 |
Interpretation: Abnormal venous blood gases. Discussion: Assessment of venous blood gases (VBG) has a rapid turn-around time. VBGs are used to evaluate the effectiveness of oxygen and carbon dioxide exchange and acid/base balance, which are critical indicators of tissue perfusion.
PT/INR
|
Name |
Value |
Units |
Reference Range |
|
Prothrombin time (PT) |
16.5 |
seconds |
11-15 |
|
International Normalized Ratio (INR) |
2.0 |
0.8-1.1 |
Interpretation: Abnormal PT/INR. Discussion: Coagulation studies are critical. Coagulopathies can quickly worsen in a patient with shock, leading to uncontrolled hemorrhage and death.
Urinalysis (UA)
|
Name |
Value |
Units |
Reference Range |
|
Color |
Dark amber |
Interpreted by physician |
|
|
Clarity |
Clear |
clear |
|
|
Odor |
Strong/normal |
slightly nutty |
|
|
pH |
5.5 |
4.5-8 |
|
|
Protein |
4 |
mg/dL |
0-8 |
|
Specific gravity |
1.030 |
1.002-1.030 |
|
|
Osmolarity |
> 400 |
mOsm/L |
>400 |
|
Leukocyte esterase |
Negative |
Negative |
|
|
Nitrites |
Negative |
0 |
|
|
Ketones |
Negative |
Negative |
|
|
Bilirubin |
Negative |
Negative |
|
|
Blood (heme) |
Negative |
Negative |
|
|
Urobilinogen |
0.5 |
EU/dL |
0.2-1.0 |
|
Crystals |
Negative |
Interpreted by physician |
|
|
Casts |
Negative |
hyaline casts/lpf |
0-4 |
|
Glucose, urine |
Negative |
Negative |
|
|
White blood cells (WBCs) |
4 |
hpf |
0-5 |
|
Red blood cells (RBCs) |
3 |
hpf |
0-5 |
|
Red blood cell casts |
Negative |
Negative |
|
|
SQEP |
0-1 |
lpf |
<5 |
|
Bacteria |
Negative |
Negative on spun specimen |
|
|
Creatinine |
14 |
5-19 |
|
|
Occult blood |
Negative |
Negative |
Interpretation: Abnormal UA. Discussion: Concentrated urine consistent with prerenal pattern; see serum BUN and creatinine. If present, abnormal UA findings consistent with a urinary tract infection could point to an etiology for sepsis. Amylase, serum
|
Name |
Value |
Units |
Reference Range |
|
Amylase |
115 |
units/L |
25-100 |
Interpretation: Abnormal elevation.
CT abdomen/pelvis with IV contrast
Results: CT scan of abdomen with oral contrast demonstrates a large central area of edema inclusive of collections of blood. Marked bowel distention. Findings consistent with duodenal hematoma.
Interpretation: Abnormal CT of abdomen/pelvis with IV contrast.
Discussion: CT scan of abdomen with contrast is the most advantageous imaging modality to use in an ill patient like Tommy.
· The study is quick.
· It lets you evaluate retroperitoneal, as well as peritoneal organs for blood/hematoma, perforation, and masses.
· With the addition of IV contrast, CT allows for identification of areas of ischemia and infection such as bowel ischemia or pancreatitis.
· With an oral contrast agent, Ct can also identify areas of intestinal obstruction, volvulus, masses, hematoma, or perforation.
Skeletal survey (x-rays)
Interpretation: Abnormal skeletal survey.
Findings:
Upright AP chest and abdominal x-ray (babygram) reveals the following:
· Acute rib fracture, left 8th
· Healing rib fractures, right 4th and 5th
· Old rib fractures, right 9th and 10th
· Chest x-ray otherwise without evidence of active disease
· NG tube and Foley catheter in place
· No free abdominal air (pneumoperitoneum)
· Diffuse bowel distention
· No evidence of pneumonia as a source of infection
· No other evident fractures per limited survey of the extremities.
Discussion:
· A skeletal survey is necessary and mandatory in assessing other injuries in a pediatric patient younger than two, who is suspected to be a child-abuse victim.
· The survey may be considered in selected, at-risk cases involving older children.
· A full series would include bilateral extremities, skull and chest/abdomen/pelvis (babygram)
· In this case, there is clinical suspicion of a nonaccidental abdominal injury; while not mandatory it would be very prudent to order this study.
Head CT
Results: CT of brain within normal limits.
Normal
0
false
false
false
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