Chisom Agbim, MD

HPI:

A previously healthy 3-year-old female presents to our satellite ED for constipation and left upper quadrant abdominal pain. Today, her mother has brought her to the ED because she is refusing to eat solids; however, she is tolerating fluids. She had three episodes of nonbilious, non-bloody vomiting. Her mother is unsure of the last time she had a normal bowel movement. Yesterday, she sat on the toilet and strained resulting in a very small bowel movement. Her mother has not tried any medications for constipation at home. She denies sick contacts or any recent travel. 

Her mother recalls that two weeks prior arrival, she was playing with her siblings and was kicked in her groin and abdomen and later had one pink-tinged void. That day, she was taken to her pediatrician and was told that the blood was due to minor trauma. She did not have any additional bloody voids following her visit.

Review of Systems

Constitutional symptoms: Endorses fatigue.Taking liquids well, taking solids poorly, denies fever, denies chills.

Skin symptoms: No rashes, no bruising, no abrasions

Eye symptoms: No eye pain, discharge or redness.

ENMT symptoms: No sore throat, no nasal congestion.

Respiratory symptoms: No shortness of breath, no cough, no wheezing.

Cardiovascular symptoms: No chest pain

Gastrointestinal symptoms: Endorses left upper quadrant abdominal pain, three episodes of vomiting and constipation.

Genitourinary symptoms: One episode of hematuria two weeks ago, no urinary frequency.

Musculoskeletal symptoms: No muscle pain.

Neurologic symptoms: No headache, no altered level of consciousness.

Health Status

Allergies:  No Known Medication Allergies.

PMH: Negative

PSH: Negative

Social History: No recent history of travel. No known sick contacts

Physical Examination

Vital signs: T 38.7C, HR 159, RR 42, BP 98/70, SpO2 98%

General Tired appearing, laying in bed, follows commands with repeated prompting  

Skin:  Warm, dry, intact.  

Head:  Normocephalic.  atraumatic.  

Neck:  Supple.  No lymphadenopathy.  

Eye:  Pupils are equal, round and reactive to light.  Extraocular movements are intact.  No eye discharge.  

Ears, nose, mouth and throat:  Tympanic membranes clear, clear oropharynx, cracked lips, dry mucus membranes

Cardiovascular: Tachycardic regular rhythm. No murmurs, rubs or gallops 

Respiratory:  Lungs are clear to auscultation. Shallow breath sounds with decreased aeration in left lower lobe.  

Gastrointestinal:  Distended and tender to palpation especially in left upper quadrant. Bowel sounds absent on left side of abdomen. The right side of abdomen is soft with normal bowel sounds

Musculoskeletal:  Moves all extremities. Strength 5/5 in upper and lower extremities

Neurological:  No focal neurological deficits

You order and abdominal x-ray and acetaminophen for the patient’s fever. The ED nurse asks whether you would like to place a peripheral IV and order labs prior to imaging.

You order a 20ml/kg normal saline bolus in addition to a VBG, CBC and CMP due to the patient’s poor po intake. A VBG returns while the patient is taken for her abdominal x-ray with the following values:

Whole Blood Sodium	134 mmol/L  LOW
Whole Blood Potassium	4.7 mmol/L
Ionized Calcium	1.10 mmol/L  LOW
pH, Venous	7.318  LOW
pCO2, Venous	43.5 mmHg
pO2, Venous	9.7 mmHg  LOW
Hematocrit, POCT	14 % PCV  LOW
HCO3, Venous	22.3 mmol/L
Total CO2, Venous	23.6 mmol/L
Base Deficit, Venous	3
Oxygen Saturation, Venous	8.1 %  LOW
Hemoglobin, POCT	4.8 gm/dL  LOW
Lactate Result (POCT)	2.07 mmol/L

Your patient returns from x-ray. You receive a call from the Radiologist with a preliminary read. She tells you that there is a “mass effect in left hemiabdomen” and the differential includes retroperitoneal hematoma, renal hematoma, splenic hematoma, or a large stomach.  She is recommending a CT for further evaluation.

You call to Hematology at the Children’s hospital who recommends a blood transfusion and the following labs before transfusion: Retic count, DAT, LDH, Haptoglobin, Hgb Electrophoresis, Iron Studies (Total iron, TIBC, Ferritin, Type and Screen). The majority of these labs cannot be done at this hospital. You decide to transfer this patient immediately. You speak with the transferring physician and make a joint decision to transfer the patient for a trauma evaluation. The patient’s labs return while awaiting transfer:

CBC: WBC 13.3 (neut 733.1, lymph 8.2%), Hgb 4.6, Hct 14.1, Plt 137

CMP: Na 127, K 5.0, Cl 99, HCO3 34, BUN 17, Cr 0.5, Glu 136, Ca 7.6, Albumin 3.0, AST 38, ALT 6, Alk Phos 99; Lipase: 20

The patient is transferred to the children’s hospital for a trauma evaluation. Her primary survey was normal except for GCS of 14 due to confusion/inappropriate words. Her secondary survey only revealed a large LUQ mass that was tender to palpation and tachycardia. She received a 5 cc/kg transfusion of PRBCs in the trauma bay before proceeding to CT of the abdomen.

The CT abdomen showed a large left abdominal mass originating from the left kidney with ruptured capsule and subacute intra-peritoneal bleeding.

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