Sunday, July 31, 2011

An 8 Year Old with Abdominal Pain

I was working in a rural health clinic seeing all sorts of patients, from 2 week old newborns to 90 year olds with congestive heart failure.  It was always something new, a different scenario with each patient, so I was always on my toes. 
            I walked into the next exam room to find a mom with her 8 year old daughter waiting for me.  Only her daughter wasn’t exactly waiting, she was definitely in pain and was trying to stay as still as she could on the exam table.  Her face told the story, tears silently cascading down her cheeks, biting of her lower lip, and her pleading eyes. 
            I introduced myself as the physician assistant in the clinic and asked the mom what was going on with her daughter.
            “She went to bed early last night because she said her tummy hurt.  She didn’t want to eat anything last night except a small bowl of soup.  Then she woke up this morning and said that her tummy still hurt, and she didn’t want to eat anything for breakfast.  She also didn’t want to go to school, which is unusual for her, she loves school.  Then as I was taking care of her younger brother, getting him ready for school, she went back into her bedroom and fell asleep again.  That’s when I had to call into work and tell them that I wouldn’t be coming in because I had a sick child at home.  She finally woke up shortly before lunch and ran into the bathroom where she started throwing up everything and anything that was in her system.  That’s when I noticed she was running a fever of about 100-101 degrees.  Now she says that it hurts down low whereas before she told me that it kind of hurt all over.”
            Turning to her 8 year old I asked her, “okay, punkin tell me where does it hurt now?  Point to one specific spot the hurts the worst.”
            The mom’s daughter, Kelly, put her finger very gingerly on her right lower abdomen.  “Here.”
            I immediately started thinking she could have an acute appy (appendicitis).  So I quickly took the child’s medical history and did a physical exam on her.  When I got to the abdominal exam, Kelly not only had pain over the right lower abdomen but she also had rebound tenderness, which told me that she most likely had peritonitis going on. I had the lab technician run a urinalysis on her to make sure she didn’t have a urinary tract infection, it was as expected, negative.  And Kelly was still running a low grade fever of 100.8.    
            As I walked back into the exam room and advised Kelly and her mom that I thought she had appendicitis, Kelly was again lying very quietly, without any obvious muscular movement on the exam table. 
“Appendicitis is an inflammation of her appendix, which is a small piece of tissue which hangs off the end of the terminal ileum.  It is common in young kids and older adults.”  Looking at Kelly’s mom I said, “she will need to have surgery to remove the appendix.” 
With that, I heard a few muffled cries from Kelly.  I turned to Kelly and told her, “Kelly, you have something inside your tummy which is causing you to have some major pain right now.  The surgeon needs to get that out.  While he does his work, you won’t feel anything, because you’ll be asleep, then after you wake up you’ll start to feel better because that nasty appendix will be gone.  Do you understand?”
Kelly nodded yes. 
I turned back to Kelly’s mom and told her I’d be back in after a few minutes.  I went to go call the general surgeon. 
I picked up the hallway phone and put in a page for the surgeon.  A few minutes later my clinic phone rang and it was an operating nurse answering for the surgeon. 
“Hi, did someone page Dr. Morgan?”
“Yes, I did.  I have a patient for him.  I believe she has acute appendicitis.  She is an 8year old who has been having pain since last night, started having nausea and vomiting at noon today and now has a 100.8 fever with tenderness over the right lower quadrant, she also has rebound tenderness.  I’m going to send her next door to the county hospital ER with orders to do a complete blood count and start an IV on her.  Can you please let him know she’ll be waiting for him in the ER?  Her name is Kelly Miller.”
“I’ll let him know.  He should be done here in about 45 minutes, so he should be down there shortly after that.”
“Thanks for your help.”
I walked back into the exam room and advised the mom to take her daughter across the street to the emergency room of the county hospital.  I told her, “Dr. Morgan will be meeting you over there in about an hour or so, he’s in the operating room right now with another patient.”
 As Kelly’s mom was walking out of the clinic, I handed her the orders for Kelly to get a complete blood count and be started on intravenous fluids for hydration.  I watched Kelly walk very slowly and gingerly towards the hospital. 
About two hours later the clinic phone rang.  The medical assistant gave me the receiver and told me it was Dr. Morgan.
“Hello, Dr. Morgan, this is Sharon.”
“Hi, I’m in the emergency room right now with Kelly, the patient you sent over for me to see.  Her mom has signed the consent forms, they’re getting Kelly ready to go to the operating room.  I just wanted to tell you her exam, and the CT of her pelvis I ordered both showed classic appendicitis.  So she should be on her way to feeling better by tomorrow.  Thanks for the referral.”
“I’m glad she’s in good hands.  Thanks for the follow-up.”
About six months later I walked into one of the clinic exam rooms to find Kelly sitting on the exam table.  Her mom was with her and told me that she had an ear infection and needed some antibiotics.  I was glad to see her.
Playfully I said, “Kelly, I’m glad you came back to see me.  How’s long is your scar from having your appendix out?  Can I see it?”
She grinned, and lifted up her shirt to show me a very short scar over her right lower abdomen. 
“So how long did you get to stay in the hospital and eat ice cream?” I asked.
Kelly gave me this quizzical look like ‘what kind of a question’ was that.  “Ice cream, I didn’t get any ice cream,” she adamantly replied.
Kelly’s mom told me, “she was in the hospital for 2 days, the day she went into the emergency room, all the following day and then was discharged the next morning.  Thanks for taking care of her then.  I really wasn’t sure of what was going on with her, but once that appendix was out she sure recovered quickly.”
“Kids usually do that, they have an amazing ability to get better and quickly.  Now let me see this ear infection, okay, punkin?”




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