Description

Attempt

T.A. is a 26-month-old male with a PMH pertinent for Downs syndrome, ASD (repaired), and CHF who presents with his mother reporting onset of abdominal pain 2 days ago with vomiting x1 yesterday. She also reports poor appetite/fluid intake, decreased diaper count with dark, foul-smelling urine, lack of BM x 2 days, and increased fussiness. Denies fever, dyspnea, and diarrhea. She endorses a recent fall from bed but denies head trauma and other injuries. Child appears lethargic and withdrawn. Exam reveals pale, mottled, cool/ clammy skin, hypotension, tachycardia, tachypnea, hypoactive bowel sounds, and indications of dehydration. Capillary refill is 3-4 seconds. Abdomen is firm, distended, and diffusely tender on palpation with rebound tenderness, involuntary guarding, and rebound tenderness. A 10cm oval epigastric ecchymosis area is appreciated. A reducible 2.0 cm umbilical hernia and diffuse diaper rash were noted. Evidence of faint circumferential macular discoloration at wrists, suspicious of aging ligature marks is of concern.

Attempt

TA is a 26-month-old M with Downs syndrome who presents with his mother with c/o abdominal pain after “falling out of bed” two days ago, one episode of emesis, and lethargy. PMH includes s/p ASD surgical repair with CHF. The mother also reports TA has been breathing more rapidly, sweating, has a poor appetite, and has diminished urine output with a dark color and strong odor. PE reveals pallor, listlessness, hypotension, tachycardia, tachypnea, grossly distended abdomen with epigastric bruising, firm to palpation with guarding, and rebound tenderness. A reducible 2cm umbilical hernia, diaper rash, and faint circumferential macular discolorations present at wrists consistent with aging ligature marks are also present on examination. A single mother raises TA with occasional help from her boyfriend and neighbors. TA is exposed to secondhand smoke. The birth father is not involved.