10-year-old boy presented with abdominal pain, fever and vomiting for 3 days. On examination, he had tenderness in his abdomen. Initial tests showed elevated white blood cell count and CRP. Imaging found fluid in the pelvis and loaded colon. He was treated conservatively but his fever persisted. Further imaging found appendicitis, abscesses and bowel adhesions. He underwent laparoscopic appendectomy and drainage of abscesses. Pus culture was negative. His condition improved with antibiotics and supportive care and he was discharged after 16 days.

1. CASE PRESENTATION
MODERATED BY UNIT-2
Dr.Aheed Khan
DNB resident
Department of Pediatrics

2. PARTICULARS
Aayush Malhotra
10 year old boy
resident of Patpargunj Delhi
informant- mother

3. CHIEF COMPLAINTS
Pain Abdomen for 3 days
Vomiting for 1 day
Fever for 1 day

4. HISTORY OF PRESENT ILLNESS
apparently asymptomatic 3 days back
generalised Abdominal pain more in Peri-
Umbillical Area
dull aching
not radiating to any site
no apparent exacerbating or relieving factors.

5. Vomiting for 1 day
non-billous

6. FEVER
for 3 days
mild to moderate grade
max being 101 F
relieved by medication
not a/w chills, rigors.

7. no h/o:
constipation, diarrhoea, abdominal distension,
jaundice, blood in stools, or hematemesis.
urinary complaints
loss of weight or appetite

8. PAST HISTORY
no h/o prior hospitalisation, TB contact, allergy,
major surgery or similar episode in the past

9. FAMILY HISTORY:
Family History: younger of two sibling
elder brother ALL on chemo
Personal history: school going 5th class student
Developmentally Normal
Birth, ante-natal, and peri-natal history is unremarkable
Immunised upto date

10. ANTHROPOMETRY
weight- 50 kg
(90-97th percentile)
height- 143cm
(25-50th percentiles
BMI

11. diet history: Non-vegetarian
exclusively breast- 6 months

12. GPE
conscious, well oriented to time, place and person
irritable, lying in bed with no signs of distress.
vitals: temp= 98 F
pulse= 103/min, normal rhythm, good volume, regular, all
peripheral pulses palpable, no RR, RF delay
BP= 100/70 mm of mercury in left brachial artery in lying
down position
resp rate- 24/min in lying down position
SpO2= 99 % at room air
No pallor, Icterus, Cyanosis, Lymphadenopathy, pedal edema, clubbing

13. ON HEAD TO TOE EXAM
head is normal in shape, no dysmorphic facies
hair and skin appears normal
oral cavity normal
eyes normal
extremities normal

14. SYSTEMIC EXAM:
Per Abdomen:
Inspection- shape normal, no distension seen, moving normally with respiration.
Umbilicus central, no visible veins, scars, visible peristalsis, all hernial sites intact, genitalia
normal.
Palpation:
Superficial palpation: soft, tenderness present over umbilical area, right
hypochondrium, right Iliac fossa. No rigidity or guarding felt.
deep palpation: no significant organomegaly or lump felt.
Percussion: Tympanic node +nt in all quadrants, no shifting dulness or fluid thrill.
Auscultation: bowel sounds normal

15. Respiratory System :
chest b/l symmetrical in shape
b/l symmetrical movement
trachea central
apex beat in left 5th ICS in MCL
air entry b/l equal on auscultation
no adventitious sounds

16. SYSTEMIC EXAM:
CNS:
higher functions- normal
cranial nerve examination- normal
motor examination- normal
sensory examination- normal
Reflexes- normal
gait- normal
meningeal signs- absent

17. CVS
s1s2 heard on auscultation
no murmurs present
apex beat in 5th left ICS in the MCL

18. DIFFERENTIALS
Acute Abdomen, ?peritonitis, ?deep seated
appendicitis
intra-abdominal sepsis
hepatitis
tuberculosis

19. SUMMARY
10 year old boy was admitted with Pain abdomen, Fever and Vomiting.
no h/o constipation, diarrhoea, jaundice, yellowish discolouration of urine.
On examination there was tenderness over abdomen in the umbillical, right
hypochondriac and right Iliac fossa.

20. day- 3
TEMP-101.7 F
hb-11.3
TLC-13000
CRP-24
Rx- Ceftriaxone+
Amikacin+
Metronidazole
0
1
2
94.5
96
97.5
99
100.5
102
103.5
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
day 1
TEMP-100.3 F
hb-11.3g%
TLC-16000
CRP-29
Platelets- 249 x 109/L
DLC- N87L7.2M4.3E0.6B0.2
BLOOD C/S- NIL
USG-FLUID IN
PELVIS,
LOADED
COLON
Rx- IV Ceftriaxone
Amikacin
metrogyl
Anti-pyretics
IV fluids
day- 7
TEMP-103 F
hb-10.6g%
TLC-16500
CRP-12.
S. Bilirubin- 0.3mg/dl
albumin- 2.8 mg/dl
bloodc/s- no growth
USG- gall bladder edema,
mild hepatitis
fluid collection in pelvis
viral markers- negative
Rx- Ceftriaxone+
Amikacin+
Metronidazole
day- 10
TEMP-99.1 F
hb-11.6g%
TLC-15000
CRP-6.9
X-ray Abdo-Multiple Air-fluid
Levels
CECT- INFLAMED APPENDIX,
SUB-HEPATIC ABSCESS,
INTRA-BOWEL ADHESIONS
AND THICKENING
SURGERY WAS PLANNED
Rx- Ceftriaxone+
Amikacin+
Metronidazole+
Piperacillin+ Tazobactam
day- 12
TEMP-102 F
Pus Gram stain- no organism
Pus c/s- no growth
Rx- Ceftriaxone+
Amikacin+
Metronidazole+
Meropenem
VANCOMYCIN ADDED
FEVER
[in deg F]
day- 11
TEMP-99.9 F
DIAGNOSTIC LAP DONE
Rx- Ceftriaxone+
Amikacin+
Metronidazole+
ALLERGIC TO PIPTAZ SO
MEROPENEM ADDED
day- 16
TEMP-98 F
ORAL INTAKE
IMPROVED
DISHARGED
NOVEMBER 2017

21. SURGICAL FINDINGS
* Diagnostic Laparoscopy with Laparoscopic Appendectomy
* Gross Peritoneal Contamination of Purulent Material with dense ad
* Two intra-abdominal abscesses seen in the sub-hepatic and right p
* supra-pubic port was put in right para-colic space.
* Pus Gram stain was negative with no growth in culture

22. thank you