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.

PLEASE SEE ATTACHMENT. MAKE SURE TO SEPARATE ALL THE TOPICS. ALSO MAKE SURE REFERENCES ARE PEER REVIEWED ARE DATED FROM 2011 TO PRESENT. Thanks. SEE TA’s LAB RESULTS below

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.

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