SUBJECTIVE DATA
CC: “She feels malaise with abdominal pain.”
HPI: XY is a 12-year-old female who complains of discomfort with abdominal pain
and pointing to her right lower quadrant (RLQ). The patient has been vomiting and
feeling nauseated for several days. The abdominal pain has been insidious and now
more pronounced. Both parents are with her and are concerned because she has not
been eating and has had a fever for the past three evenings.
Medications: Tylenol 3 chewable tabs (160 milligrams per tab) every 4 to 6 hours
for fever and pain.
Allergies: Shellfish
PMH: No previous medical history.
PSH: Tonsillectomy 2010
Personal/Social Hx: Lives at home with both parents, who both have jobs outside
of the home. She goes to public school and denies any ETOH, illicit drugs and
smoking. She has multiple friends and denies feeling bullied at school. She denies
having a boyfriend at this time.
Immunization History: Her immunizations are up to date. She received her
influenza last year. She received her second HPV vaccination last month next one is
due in five months.
Significant Family History: Father diagnosed two years ago with hypertension
(HTN), Mother is in good health. XY is an only child.
Lifestyle: She has medical insurance through her parents. She is activity involved in
school functions and plays basketball.
ROS:
General: Denies fatigue, chills or night sweats. No changes in her weight.
See HPI.
HEENT: No changes in hearing, no recent infections, tinnitus, or discharge.
No vision changes, does not wear glasses, last exam was right before school
started this year. She denies floaters, excessive tearing or photophobia. Her
sense of smell is intact. Denies epitaxies, or sinus infections. She denies
ulcerations, lesions, gingivitis, gum bleeding, no dental appliances, last exam
was 6 month ago. No difficulty chewing or swallowing.
Neck: N/A
Breasts: N/A
Respiratory: Denies cough, hemoptysis. No difficulty breathing.
CV: No chest discomfort, palpitations, murmur. Denies orthopnea.
GI: See HPI. Pain started by the navel and moved to the RLQ. Denies changes
in bladder pattern. Having problems with constipation.
GU: No changes in her urinary pattern, dysuria or incontinence. No pain
noted. She denies having sex yet.
MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her
range of motion. No history of trauma or fractures.
Psych: No history of anxiety or depression. No sleep disturbance, delusions
or mental health issues. Denies suicidal/homicidal ideations. She social hx.
Neuro: No headaches, dizziness, or syncope. No changes in memory or
thinking patterns, no twitches or abnormal movements. No falls or seizures.
Integument/Heme/Lymph: No rashes, itching or lesions. See HPI.
Endocrine: N/A
Allergies/Immunologic: Denies seasonal allergies and no known immune
deficiencies.
OBJECTIVE DATA
Physical Exam: Vital signs: B/P 124/72, left arm, sitting, small cuff; P 112 and
regular; T 100.2 orally; RR 14 nonlabored; Spo2 96 % on room air; Wt. 98 lbs.; Ht. 4’
10”; BMI 20.
General: A & O x 4, well-groomed and dressed appropriately. Appears anxious and
holding RLQ. Appear to be uncomfortable.
HEENT: PERRLA, EOMI. Oroanaxophyarynx is clear.
Neck: N/A
Chest/Lungs: CTA AP & L
CV: Heart rate slightly tachycardic, S1 and S2 good. No S3, S4 or murmurs noted.
Pulses +2 bilat pedal and radial.
ABD: NABS x 4, no organomegaly. Slight abdominal distension noted. Tenderness
noted in the RLQ. Positive for rebound pain and guarding.
Genital/Rectal: N/A
MS: Steady gait, grasp equal and strong bilaterally
Neuro: N/A
Skin/Lymph Nodes: Skin warm and dry. No palpable nodes.
Assessment:
Lab:
Diagnostics:
Lab: CBC – WBC 18, 000, UA negative for WBC and RBC, Occult stool -
negative
Radiology: Abdominal Ultrasound – appendix show thickening of the wall,
diameter > 6mm and free fluid surrounding the appendix (Mostbeck et al.,
2016).
DDX:
1. Appendicitis
2. Urinary Tract Infection (UTI) – Dains, Baumann, and Scheibel
(2016) advised that abdominal pain is common in children and
sometimes can be the only indication of a UTI.
3. Pelvic Inflammatory Disease (PID) – Ball, Dains, Flynn, Solomon,
and Stewart (2015) gets associated with tenderness, and the patient
shows signs of guarding.
4. Ileus – Signs of an ileus are abdominal pain, loss of appetite,
inability to have a bowel movement and distention of abdomen
(Mayo Clinic, 2015)
5. Meckel’s diverticulitis – abdominal pain and cramping, tenderness
near the navel, bloating and constipation are common symptoms
(Cleveland Clinic, 2017).
Diagnoses/Client Problems:
1. Appendicitis
Rational
Appendicitis is an inflammation of the appendix, a pouch in the shape of a finger that
projects from the colon in the RLQ of the abdomen. The common symptoms that XY
showed for this condition were RLQ pain, pain around the navel, nausea, vomiting, loss of
appetite, low-grade fever, bloating and constipation (Mayo Clinic, 2014). The increase in
WBC on the CBC will help to determine that the appendix is infected. The positive physical
findings in the exam like rebound pain and guarding will alert the medical doctor (MD) that
there is a problem in the RLQ. The negative UA will help eliminate UTI and kidneys stone
which can also cause pain in the RLQ. The negative occult blood will help eliminate Merkel’s
diverticulitis. The positive abdominal ultrasound will determine the diagnosis of
appendicitis.
