rmonroe please you also have all my files for this course, please give a peer response on this case study, only build off the post no critiquing or being mean be polite and nice

the post to give a review on……………………………………..

Today you note that both Jo and Riley are on your schedule for ill visits 4 months after your last visit.

Current ages: Lily 16 year-old female, Riley 24-month-old male

HPI: Both the oldest and youngest children in the house have had several episodes of vomiting over the last 2 days and have developed diarrhea in the last 24 hours. Lilly has not vomited today, but Riley vomited twice this morning in small amounts since awakening. They have both had low-grade fevers of around 100 to 101 degrees in the afternoons. Mother reports that both have not eaten solid food since 36 hours prior to this visit, when they went to a pizza buffet in a town nearby. They have been keeping down some sprite, apple juice, and popsicles. Both urinated this morning. Mother has given both children Pepto-Bismol over the counter (OTC) to prevent an upset stomach and acetaminophen two to three times a day for fever, but she reports that Riley vomited soon after his dose this morning. Lilly is complaining of some lower abdominal pain starting this morning, but also reports she has started menses today. Lilly complains also of headache, myalgia. Her pain is a 5 on a 1-10 scale and has progressed in the last hour. No other household members are ill.

PMH: No updates on either child since last visit. Riley is no longer on Zyrtec.

Discussion Questions Part One:

What further OLDCART and ROS information is important today specific to their chief complaints? What are their chief complaints/concerns?
What are the differential diagnoses based on the chief complaints for Lily and Riley with rationale?

Infectious gastroenteritis non specified (A09):

“Gastroenteritis is a common disease in children, characterized by diarrhea, vomiting, abdominal pain, and fever. Pediatric gastroenteritis remains the second most common cause of child mortality worldwide. In developed countries it is a common cause of hospitalization, especially in young children, leading to a high social burden and economic costs due to hospital care of the ill children and absence of parents at work. Diarrheal disease can be caused by a wide spectrum of parasitic, bacterial, and viral pathogens. Enteric viruses are the most common cause of acute gastroenteritis in children”. (Corcoran, et., al., 2014). Rotavirus is the most common virus and is usually acquired by small children who attend daycare.

Viral Intestinal Infection (A08):

“Influenza is a respiratory illness. Symptoms of flu include fever, headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose, and muscle aches. Some people, especially children, can have additional gastrointestinal symptoms, such as nausea, vomiting, and diarrhea” (Deriu, et., al., 2016).

Urinary Tract Infection (N39.0):

“Urinary tract infections (UTI ) are a common bacterial infection in infants and young children resulting in morbidity and mortality. Urinary tract infections are common in children with an estimated incidence of 1-3% in boys and 3-10% in girls The long term consequences of UTI are renal parenchymal damage and renal scarring that can cause hypertension and progressive renal damage. The signs and symptoms of UTI are nonspecific in infants and young children and also they do not usually pertain to the genitourinary tract. Gastrointestinal symptoms of poor feeding, vomiting, abdominal pain and diarrhea are reported in many infants with UTI1 and also diarrhea can predispose infants and young children to develop UTI” (Narayannappa, et., al., 2015).

Additional Differential Diagnosis for Lily:

.

Acute Appendicitis (K35.80):

“Acute abdominal pain is a common complaint among children presenting to the ED. Approximately one in 10 of these children with abdominal pain will have acute appendicitis. As the most common reason for emergency surgery in children, appendicitis is an important diagnosis in such patients and a delay in making the diagnosis increases the risk of perforation, complicated surgery and overall morbidity. However, due to its often varied presentation and the many potential causes for abdominal pain in children, definitively diagnosing acute appendicitis in this age group can be difficult, with quoted rates of missed appendicitis of up to 57%. (McCabe, et., al., 2014).

“Acute appendicitis is the most common surgical emergency in children and adolescents in the United States, with an incidence of two to four cases per thousand children. An accurate diagnosis of appendicitis in pediatric populations remains a challenge for physicians due to the initial presentation of this disease is often obscure or mimics other common pediatric conditions. The diagnosis of acute appendicitis can be defined by findings in the patient’s history, physical exams, and initial laboratory test performed during the clinical evaluation” (Epifanio, et., al., 2016).

Unspecified Ovarian Cyst (N83.20):

Ovarian cysts are usually on the ovary surface and are like pockets or sacs filled with fluid. These cysts may or may not produce physical unease and are usually benign. Many ovarian cysts dissolve without treatment because they are generally functional in nature. Menstrual disorders can be of different types. This may include periods which range from painful heavy bleeding to no periods. The patterns of menstrual cycle have many variations. Females should only worry when generally the bleeding starts before 21 days or greater than 3 months apart and if the bleeding persists for more than 10 days.

Questions for Lily:

O: When did the vomiting and diarrhea first start? (vomiting the last 2 days, diarrhea past 24 hours. When did Lily begin having abdominal pain? (started this am)

L: Where is the abdominal pain, does it move to any other place?

D: How long does the pain last? Is it constant?

C: Besides the pain what other symptoms do you have? Vomiting, diarrhea? Fever?

A: Does anything make the pain worse? Movement? Does it hurt to walk? Jumping up and down on right foot?

R: Does anything make the pain better? Rest? Position changes?

T: Does the Pepto-Bismol or Tylenol make you feel better?

S: How severe is the pain on a scale of 1-10 (5/10), is she able to go to school?

“Five findings that are consistently associated with appendicitis have been identified in children: nausea, focal right lower quadrant abdominal pain, difficulty walking, rebound tenderness, and an absolute neutrophil count of greater than 6,750 cells per mm3 ” (Armstrong, 2010).

“Acute abdominal pain accounts for approximately 9% of childhood primary care office visits. Symptoms and signs that increase the likelihood of a surgical cause for pain include fever, bilious vomiting, bloody diarrhea, absent bowel sounds, voluntary guarding, rigidity, and rebound tenderness. The age of the child can help focus the differential diagnosis” (Carin & Williams, 2016)

Further ROS questions needed to develop differential diagnosis:

Did Riley and Lily eat the same food at the pizza buffet?, what exactly did they each eat? Did Lily attend school the same day she ate at the buffet? Is Riley in daycare? Was he at daycare the same day he ate at the buffet? How long after they both ate at the buffet did they develop the vomiting and diarrhea? Has anyone in the family traveled lately? Are there any reptiles in the house as pets?

Constitutional: Has Riley had fever or chills in the past 2 days? Skin cool or clammy to touch?

Eyes: Do Riley’s eyes look different, dark circles, sunken in? When he cries do you notice tears?

Mouth: Does his tongue have a white coating, are his lips dry?

Cardiorespiratory: Does Riley’s breathing seem normal? Does appear to be faster then usual? Does his heartbeat seem fast?

GI: How many episodes of diarrhea has Riley had? Any normal stool? Is it all loose stool? What color is it? Does it have a strange odor? Have you noticed any blood in his stool, mucous?

How many times has Riley vomited? Is it liquid or food? What color is the vomitus (Bile or green)? Have you noticed any blood?

GU: Is Riley potty trained, if not how many wet diapers has he had in the last 24 hours? If he is how often has he urinated?

Neuro: Has Riley been alert and playful the last 24 hours? Is he sleeping more? Does he seem more fussy then usual?

“Dehydration and disturbances in electrolyte balance are common complications of acute diarrheal disease in children. This is because children exhibit major physiologic differences from adults in their total body surface area, immature renal structures, endocrine systems and higher metabolic rate” (Mariere, et., al., 2015).

Reference:

Armstrong, C. (2010). ACEP releases guidelines on evaluation of suspected Acute Appendicitis. American Family Physician; 81(8): 1043-1044.

Carin, R., & Williams, A. (2016). Acute Abdominal Pain in Children. American Family Physician; 15(10): 830-837.

Corcoran, M., Van Well, G., Van Loo, I. (2014). Diagnosis of viral gastroenteritis in children: interpretation of real-time PCR results and relation to clinical symptoms. European Journal of Clinical Microbiology; 33(10): 1663-1673.

Deriu, E., Boxx, G., He., X., Pan, C., Benavidez, S., Cen, L., Rozengurt, N., Shi W., & Cheng, G. (2016). Influenza Virus affects intestinal microbiota and secondary salmonella infection in the gut through type 1 interferons. PLOS Pathogens; 14(5): 1-26.

Epifanio, M., Antonio de Medeiros, L., Correa, P., Baldisserotto. M. (2016). An imaging diagnostic protocol in children with clinically suspected acute appendicitis. The American Surgeon; 82(5): 390-39.

Mariere, O., Matthias, N., Onyiriuka, A., Abhulimhen-Iyohan, B. (2015). Point of admission serum electrolyte profile of children less than five years old with dehydration due to acute diarrhea. Tropical Medicine & Health. 43(4): 247-252.

McCabe, K., Bahl, F., Dalton, S. (2014). Management of children with possible appendicitis: A survey of emergency physicians in Australia and New Zealand. Emergency Medicine; 26(5): 481-486.

Narayannappa, D., Rajani, H., Sangameshwaran, A. (2015). Study of Urinary Tract Infection in infants and young children with acute diarrhea. Indian Journal of Public Health Research & Development; 6(2): 226-229.