Tuesday, January 31, 2012

Acute Appendicitis in a 9 year old Child


               I was working in the rural health clinic, thankfully it had been a quiet morning.  I was looking forward to having lunch shortly, seeing that I had only managed to eat a small amount for breakfast, due to my waking up late and rushing out of the door to get to work on time.
                “Sharon, there’s a little 9 year old girl with her mom who just checked in at the front desk.  She’s crying.  Can you please see her before you leave for lunch, please?” pleaded my medical assistant. 
                “Okay, Carla,” I said as I let out a sigh.  “You check her in and I’ll go back and at least eat my sandwich so that my stomach will quit growling.  Agreed?”
                “Agreed, thanks Sharon,” sighed Carla.
                I scurried back to the break room and grabbed my lunch bag out of the refrigerator.  I ate my sandwich so fast, even I was surprised.  I had just eaten the last bite of it when Carla’s head popped around the corner of the door.
                “She’s ready for you, Sharon.  She’s in room two.”
                “Thanks, Carla.”
                I put the rest of my lunch back in the refrigerator and walked down the hall to exam room two.  I knocked on the door and went into see an upset little girl.  I was thinking she probably had a painful ear infection or strep throat.  But what she had, I was definitely not expecting. 
                “Hi, I’m Sharon.  And your chart here says that you’re Melody, is that right?”
                 Melody, sitting uncomfortably on the exam table, nodded her head ‘yes.’
                I immediately noticed that she was in real pain and this wasn’t just an ear infection, she was wiggling around trying to find a comfortable way to sit without pain.  She also had a white chalky look to her face. 
                “Melody, would it help if you laid down on the table?”
                She nodded, ‘yes’ and slowly laid down on her back.
                I turned to her mom and asked her what had happened during the last day or so to bring this pain on.
                “Melody didn’t eat a whole lot yesterday.  She went to school and they called me around lunch and said that she was complaining of being tired and had fallen asleep.  I went and picked her up and brought her home.  She took a nap and when she got up she said that she just didn’t feel well.  She didn’t eat anything for dinner last night, she just wanted some watered down 7-up and that was it.  I noticed that she started running a low grade fever last night.  She went to bed early.  I was woken up around midnight when I heard her in the bathroom throwing up.  She threw up a couple of times, just yellow fluid mostly.  She told me that her stomach hurt, but nothing else.  I thought she probably just had the flu seeing that it was going around her school.  So I let her go back to bed and she woke up this morning with a fever of 101 F.  So after I got her brother off to school, I finally got her dressed and came over here.”

Patients who could have acute appendicitis acquire it due to blockage of it’s small opening into the intestine or from undigested food or other foreign matter that gets caught in it.  It is the most common condition in children requiring emergency abdominal surgery. 

                I turned to Melody and asked, “Okay, Melody, where in your tummy does it hurt?”
                Melody pointed to her right lower quadrant of her abdomen.
                “Okay, Melody is that where it hurt last night when you told your mom that your stomach hurt?”
                Melody nodded, ‘yes.’
                I quickly looked at the vital signs Carla had taken and noticed that her fever was 101.4 F.  Her pulse was a little on the high side. 
                “Melody, when was the last time you had anything to drink?”
                Melody answered in an almost inaudible voice, “this morning.”
                I turned back to her mom and asked some more questions.
                “Is she on any medications for asthma, or allergies or anything?”
                “No, she doesn’t take anything.”
                “Is she allergic to any medications?”
                “No.”
                “What’s the family history?”
                “I have high blood pressure, her father has type 2 diabetes.  Her grandparents have some heart problems.   That’s it.”
                “Okay, great.  Let me do her physical and then I’m going to send her across the street to the county hospital’s lab to get some labwork done.  But I can tell you right now that she doesn’t have the flu.  I think she has appendicitis.  If the labwork shows what I think it will, then she’s going to need to be seen by a general surgeon to have her appendix taken out. “
                With my saying that, Melody’s eyes enlarged and she gave me this pained look on her face. 
                I looked Melody directly in the eyes.  “Melody, I think you have a little tiny piece of your intestine that is causing you a major problem right now.  If I’m right, then it can be taken care of very easily.  The doctor that I’ll send you to will put you to sleep and then he’ll make a lttle incision with his instrument in your lower abdomen right where it hurts, snag this little piece of intestine, what we call an appendix and remove it from your abdomen.  You’ll then wake up and feel so much better.  Do you understand that?”
                Melody  nodded ‘yes’.
                “Okay then, Melody, I need to feel your tummy  and listen to your chest.  I’ll try real hard to not hurt, but if it does you have to tell me, agreed?” I asked her.
                Through her ever increasing watery eyes, Melody nodded, ‘yes.’
                I took out my stethoscope and put the end piece on her chest wall to listen. I had her roll over so I could listen to her back side.  I then listened to her heart sounds.  Everything was normal.  I gently put the end of my stethoscope on her abdominal wall and listened.  It was unusally quiet.  Taking the stethoscope end piece out of my ears, I wrapped it back around my neck. 
                “Okay punkin, now I need you tell me when it hurts as I feel all around your abdomen.  I’ll be gentle as possible.”
                As I felt her abdomen, first away from where it hurt and then started moving my hand over her right lower quadrant she was becoming more apprenhensive.  I knew then, that if I tried to palpate where it hurt she would not trust me to finish the needed exam.  So I changed tactics a little bit.  I put my hands down by my side and asked her a question.
                “Melody, I want you to use one of your fingers and I want you to put that finger right where the pain hurts the worst.”
                With a tear running down the side of her face, Melody moved her right hand and used her second finger to touch her lower right abdomen just above her hip bone, almost midline.  She was pointing right at McBurney’s point, the anatomical spot where the appendix lies.
                “Okay, punkin, you can put your hand back down.  I won’t touch where you pointed your finger.  I’m going to send you across the street to the county hospital’s lab to get some tests done and once you’ve done that you can come back in this room and lie down.  So I’ll give the lab slip to your mom and the two of you can walk across the street.  I’ll see you again once I get the lab results back.”
                With that I gave her mom the lab slip.  The two of them left the room, Melody walking very gingerly and slowly.   I quickly went back into the breakroom and grabbed the rest of my lunch and ate it while Melody was across the street at the hospital’s lab.

Patients who have acute appendicitis will generally present with nausea, vomiting, anorexia, abdominal pain, fever, right lower quadrant pain, and sometimes diarrhea or constipation. Patients can also have guarding of their abdomen due to the pain and/or rebound tenderness (this is where you press down with your hands and then let up suddenly, if it hurts, then this is considered rebound tenderness). 

As a part of the physical examincation you can have the child hop on one foot, if this elicits pain in their abdomen, it is considered a positive sign. You can also internally rotate their right leg (i.e. turn the leg towards the midline), if this elicits pain then it is considered positive. 

If a patient is suspected of having acute appendicitis the amount of lab work/radiology tests you need depends upon the age of the patient.  If they are a child or adolescent you typically only need to acquire a complete blood count (which should show an elevated neutrophil count).  Neutrophils are a form of white blood cells and they fight off bacterial infections.  You should also acquire an urinalysis to make sure that the problem is not coming from a urinary tract infection.  If the child does not have the typical findings for appendicitis, then it is advisable to acquire an abdominal ultrasound or CT study of the abdomen to ascertain the status of their appendix (is it inflammed vs. does it look normal in size).

Some pediatricians and surgeons will use what is called a pediatric appendicitis score.  The patient is given 1 point for their physical exam findings, laboratory findings and/or radiology test results.  If the patient has a score of 7 or above then they are considered at high probability of having acute appendicitis. 

If the patient is an adult then you also typically need to acquire a CT scan of their pelvis after you have made sure that if it is a female patient they are not pregnant. 

                About 45 minutes later, Melody and her mom walked back into the clinic and Melody proceeded to slowly crawl back up on the exam room table and laid down.  About 30 minutes later the hospital lab called me with Melody’s stat lab results.
                The lab results confirmed what I thought they would.  Her urinalysis was normal, and her complete blood count showed a high total white blood cell count with a high neutrophil count (neutrophils are used to fight off bacterial infections).  So these lab values confirmed what I thought, Melody had appendicitis. 
                I walked back into the exam room and advised Melody and her mom that she would need surgery.  I called the emergency room next door at the county hospital and asked who was the general surgeon on call.  They asked why, I advised them of Melody’s condition.  The emergency room registered nurse said she would immediately put in a page for Dr. Thomas.  I asked her to call me back when he had replied.   About five minutes later I received a call back and the county hospital advised me that Dr. Thomas had called and he was on his way in to see Melody and to send her over.
                I walked back into the exam room and advised Melody and her mom that Dr. Thomas was on his way in.  Melody sat up and slowly starting to get down off of the exam table.  She again walked slowly and gingerly down the hallway towards the front door.  She was followed by her mom.  They moved slowly back across the street and walked into the emergency room. 
                About an hour later, Dr. Thomas called me and advised me that Melody did indeed have appendicitis and he was taking her to the operating room as soon as they could get her an intravenous dose of pre-op antibiotics.  He thanked me for working her up and he expected her to do just fine, he didn’t think her appendix had ruptured.
                A day and a half later I walked into the rural health clinic and was given a telephone note from Carla.  The note was from Melody’s mom.  It basically said, ‘thank you, Melody is going home this morning.’  I was glad that she had done so well and would soon be back to her normal self. 

Typical treatment for acute appendicitis consists of:
prompt general surgery consult
intravenous antibiotics
intravenous fluids for hydration
pain control
surgery: usually can be done with a laprascope (1 inch incision) to remove the inflammed appendix
hospital discharge generally within 24-36 hours



Again, thanks for reading.  I solicit your comments and feedback.  –sharon

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