Description

Collection

Tommy Acker – 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 Child appears lethargic and withdrawn.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.

Tommy Acker – 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.

Tommy Acker – Attempt

TA is a 26-month-old male with trisomy 21 presenting with a 2-day history of abdominal pain, anorexia, and oliguria. Per the mother, symptoms began after a reported fall from the bed during a nap while in the care of her boyfriend. The child has not had a bowel movement for 2 days, is lethargic, and vomited once the previous night. Physical exam reveals tachycardia, tachypnea, hypotension, pallor, cool, clammy skin with mild mottling, and lethargy. Capillary refill is delayed at 4 seconds. Positive findings include dental caries, diffuse diaper dermatitis, hypoactive bowel sounds, a distended, firm abdomen with epigastric ecchymosis, tenderness, guarding, rebound tenderness, faint wrist discoloration suggestive of aging ligature marks, and a systolic murmur. Negative findings include afebrile , clear lung fields without adventitious sounds, and no head trauma. History includes AV septal repair for CHF and developmental delay. The child is exposed to secondhand smoke, childcare is primarily provided by the mother’s boyfriend or neighbors.